2017 spring presentation · • claims have been back through for reprocessing once we identified...

Quality health plans & benefits

Healthier living

Financial well-being

Intelligent solutions

Spring Updates 2017

1

Aetna’s Values Wheel

2

Aetna OfficeLink Updates

Stay up to date with quarterly newsletters

Aetna OfficeLink Updates

• Located on www.aetna.com > Health Care Professionals > Newsletters and News.

• Sign up to have delivered right to your email.

Information you will find in the newsletters

• National Precertification reminders and updates

• Policy and coding updates

• General Office news

• Pharmacy updates

• Mid-America News specific to Nebraska and Iowa

3

Provider Office Manuals

Aetna and Coventry’s provider office manuals are available on our

websites to help keep you informed.

Aetna provider office manual

• www.aetna.com > Health Care Professionals > Education & Manuals >

Explore provider manuals

• Navinet.net > Aetna Health Plan > Resources

Coventry provider office manual

• www.chcnebraka.com > Providers > Document Library > Commercial

Guides/Manuals

4

Provider Service Center

Aetna Provider Service Center is ready to service you

• Our Provider Service Center (PSC) is the first point of contact if you

need help with a claims issue.

– Make sure you’re familiar with our self-service tools and

solutions, which are available to you 24/7. These include:

• NaviNet, our secure provider portal

• Our Aetna Voice Advantage self-service telephone system

• If you have questions, call us at 1-888-632-3862

5

Provider Service Center Tips

Tip for claims resolution:

• Providers should call the Provider Service Center (PSC) or submit an inquiry through NaviNet for Aetna plans.

• Request the claim to be submitted for reprocessing/review. If just checking the claims status the PSC representative will not send the claim through for reprocessing without a request to do so.

• Ask to speak to a supervisor - If you feel you are not getting the answer from the representative. If communicating via secure messaging through the provider portals, please request a supervisor reach out to you and provide your phone number.

• Write down all reference numbers and names.

• If after speaking to a customer service representative and supervisor does not correct the issue, then please reach out to Provider Relations and provide reference numbers.

Providing the reference numbers and names will help Aetna provide education and track

trending issues.

6

Aetna Appeal Process Changes

Changes to the provider appeal process

We’ve streamlined the provider appeal policy for members enrolled in commercial plans by:

• Eliminating level 2 appeals for practitioners

• Requiring the use of a specific form when submitting appeal requests (Form attached)

The Form can be found at www.aetna.com - Healthcare providers - Disputes & appeals - Learn about the dispute process - Find dispute and appeal forms - Disputes and Appeals - Practitioner and Provider Complaint and Appeal Request Form.

These changes will help ensure that we have the information we need to get the request to the appropriate area and to do a full review.

Learn more

• Please visit our Disputes & Appeals section of www.aetna.com for additional information

7

Disputes, Reconsiderations & Appeals

8

Our process for disputes and appeals

Health care providers can use the Aetna dispute and appeal process if they do not

agree with a claim or utilization review decision. The process includes:

• Reconsiderations: Formal reviews of claims reimbursements or coding

decisions, or claims that require reprocessing.

• Level 1 appeals: Requests to change a reconsideration decision, an initial

utilization review decision, or an initial claim decision based on medical

necessity or experimental/investigational coverage criteria.

To help us resolve the dispute, we'll need:

• The reasons why you disagree with our decision

• A copy of the denial letter or Explanation of Benefits letter

• The original claim

• Documents that support your position (for example, medical records and office

notes)

Dispute, Reconsideration & Appeals Links

For additional information on time frames, turn around times, forms, and

addresses where to send disputes, reconsiderations, and appeals please

visit:

www.aetna.com > Health Care Professionals > Dispute & Appeals Process

www.chcnebraska.com >Services & Support > Providers > Document

Library > Provider Manual

9

Aetna LeapAetna Leap Helpful Facts

• Aetna Leap = Aetna Individual Member Plans

• CoventryOne Carelink plans transitioned to Aetna Leap plans beginning 1/1/17

• Aetna Leap members have Digital ID cards. – Aetna Leap members have access to show their ID card from their smart phone, print a

copy via the member website, or can request a plastic copy be mailed to them.

• NaviNet is the secure provider website for verifying eligibility, benefits, checking precertification, beginning an authorization and to check claims.

• Claims mailing address, electronic payer ID and contact phone are the same as Aetna’s.

– Electronic Payer ID 60054

– Provider Service Center – 1-888-632-3862

10

Aetna Leap

Aetna Leap Networks Offered in Nebraska and Southwest Iowa

Aetna Leap CHI Health – Includes CHI Health, UniNet PHO, Children’s Hospital and

SecureCare providers. Offered to members living in Douglas, Sarpy and Pottawattamie

counties.

Aetna Leap Nebraska Health Network – Includes Nebraska Medicine providers

and facilities, Methodist PHO providers and facilities, Children’s Health Network,

Children’s Hospital and Medical Center and SecureCare providers. Offered to

members living in Douglas, Sarpy, Pottawattamie and Mills counties.

Aetna Leap MIPPA – Includes all providers except CHI/UniNet PHO providers &

facilities. Offered to members living in Douglas, Sarpy and Pottawattamie counties.

Aetna Leap – Includes all providers contracted with Aetna. This is a full network of

providers and was offered to members living in all counties in Nebraska (excluding

Douglas & Sarpy).

11

Aetna Leap Plans

How can I get a copy of the ID card?

Providers can view eligibility and a copy of the member ID cards on NaviNet.

How am I contracted with Aetna Leap?

Nebraska Providers are contracted with Coventry. Aetna aquired Coventry and

assumed the Coventry contracts. Aetna Leap is an individual plan that utilizes

these contracts. Aetna is currently in the process of re-contracting with all

Coventry contracted providers, moving providers to an Aetna contract.

How can I tell if I am in network with an Aetna Leap plan?

Visit DocFind referral directory and search for your provider group under the

specific member’s plan.

What payment will I receive for an Aetna Leap member?

Payment should mirror your Aetna contracted rate, unless a different rate is

contracted specifically for the Aetna Leap product.

12

Aetna Leap Identified Issues

Transition issues seen so far in 2017 • Providers were not showing appropriately in directories

• Contracts were not set up correctly in the Aetna Leap claims payment system

• Providers were not set up correctly for the Aetna Leap plans

What we are doing to correct issues

• We have updated directory flags so providers show up in the directories appropriately.

• We have identified provider set up issues and contract load issues. We have completed some mass updates. This is an ongoing project.

• Claims have been back through for reprocessing once we identified and corrected the issue/provider set up.

13


Claims Projects Currently Being Worked

• Midlevel Provider Reductions - Reprocessing claims back to 1/1/17 to not

apply this reduction.

• Multiple Procedure Reductions were not being applied correctly – this has

been corrected and claims reworked.

• We are looking at the first quarter of all claims that were processed as out

of network by Tax ID and for what member network. We will be making

updates to providers and reprocessing claims beginning this month.

14


Identifying the plan in NaviNet or your electronic vendor

• If the eligibility response for an Aetna Leap member is unclear, providers

must click to view the copy of the member ID card to view the full Aetna

Leap plan name.

15

Aetna & Coventry ProductsCoventry Products in 2017

• Coventry Health Care of Nebraska – small group businesses who stay with our company will be offered Aetna plans at renewal time in 2017

• Coventry Advantra & Coventry Advantra Total Care – These Advantramembers will remain on a Coventry Advantra and Coventry Advantra Total Care plans for now. No transition date to Aetna Medicare at this time.

• By the beginning of 2018, Coventry will only have Coventry Advantra &

Coventry Total Care products in Nebraska and southwest Iowa.

Aetna Products in 2017

• Aetna – several plan types offered under Aetna (POS, PPO, etc.)

• Aetna Leap – Individual HMO and POS based plans

• Aetna Medicare – Employer groups who have retirees, the retirees are on an Aetna Medicare plan

• Aetna Whole Health – Group employer plan with a CHI Health/UniNetnarrow network

16

Rental Network Plans

17

Aetna & Coventry’s rental networks. These are networks that various payers

access.

As a reminder, you should send all claims for ASA and First Health Network

electronically to the payer ID listed on the member’s ID card. Send paper claims

only to the address listed on the ID card.

Direct all ASA and First Health Network claim questions to the appropriate payer

on the ID card.

Help members save by staying in network

Check your participation status

Aetna Provider Search - Docfind

• www.aetna.com > Find a Doctor > Select the members’ plan within your search

Coventry Provider Search

• www.chcnebraska.com > Find a Doctor > Enter provider search > Select the members’ plan

When referrals are recommended for a consult/procedure, refer members within their specific networks. Also, please make sure that your practice is in network with the member’s plan prior to seeing the member. Many members have limited provider networks and may have to pay more if they go out of network.

See attached handout for additional search instructions.

18

NaviNet Webinars

Every month, our Provider eSolutions team offers live webinars with the

opportunity for you to ask questions. Sign up for one of our webinars to learn

how to use our self-service tools and to work efficiently and effectively with

us.

Three different classes are offered:

• Working with Aetna on NaviNet

• Claims management tools

• Precertification

Please see attached handout for additional information about registering for

a webinar.

19

Handouts

• Practitioner and Provider Compliant & Appeal Form

• Digital ID Card Guide

• 2017 NaviNet Webinars

20

Questions?

21

Thank you for caring for our members!

22


Healthier living



What you need to know about digital member ID cards

00.03.846.1 (6/16)

Our members now have access to digital member ID cards.

You can expect to see more patients showing you ID cards on

their smartphones and mobile devices. They may also carry a

self-printed copy. You can accept either format as valid proof

of coverage. But don’t worry — the digital ID card features all

the information you need.

Why go digital?

• Digital ID cards are accurate and up to date.

• They’re a more secure source of benefits information.

• Producing less plastic helps our environment.

You can verify patient eligibility without an ID card

Patients may visit your office without their member ID

number or a copy of their card. You can search for patients in

NaviNet®, our secure provider website, with the Eligibility and

Benefits Inquiry transaction. All you need is their name and

date of birth.

When you do an Eligibility and Benefits Inquiry, you’ll get all

the information you need. You can check membership, verify

coverage and see other important information, like copays,

coinsurance and deductible amounts.

You’ll have electronic access to member ID cards on NaviNet

To access the electronic image of a member ID card, submit

an eligibility request for a member. You’ll see an image of a

generic ID card on the eligibility response screen.

Simply click the image to see a copy of the member’s ID card.

Then you can download the ID card to a local computer or

network, or print it.

Note: Your NaviNet Security Officer must enable this feature.

You may not be able to see member ID card images for all

plans. Aetna LeapSM plan member ID card images will be

available in April 2016.

Availity® also offers electronic access to member ID cards.

Just visit www.availity.com/.

Still can’t find the member ID number?

You can call us at:

• 1-800-624-0756 for Aetna HMO-based plans and

Medicare Advantage plans

• 1-888-MDAetna (1-888-632-3862) for Aetna Leap,

indemnity and PPO-based plans

Note: If you don’t know the member’s plan type or don’t

have an ID number, give us a call at 1-888-MDAetna

(1-888-632-3862). We’ll connect you with someone who

can help. If prompted for an ID number, you can enter the

patient’s Social Security number.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

www.aetna.com

©2016 Aetna Inc. 00.03.846.1 (6/16)

Access the Eligibility and Benefits Inquiry transaction

Step 1 — Sign in to NaviNet.

Step 2 — Select “Aetna” from the

“Workflows” menu.

Step 3 — Select “Eligibility”

from the “Workflows for this Plan”

menu.

Step 4 — Select “Eligibility and

Benefits Inquiry.”

Search for a member without an ID number

Select the option for

“Member Name/Date of Birth.”


Healthier living



2017 provider webinars

Working with Aetna on NaviNet®

This 45-minute webinar is a “soup-to-nuts” lesson about

working with us. We cover how to contact us and identify our

products, and we discuss most of the tools and transactions

available on our secure provider website. This webinar is

great for anyone who is just getting started. We cover

registration, the role of the security officer and some of the

tools and transactions.

This webinar is offered the fourth Tuesday of every

month at 2 p.m. ET.

Claims management tools

This 45-minute webinar covers everything related to patient

accounts, including claims status, claims reports, online

Explanation of Benefits (EOB) statements, and single and

multiple claims reconsiderations. We’ll also include

information on the Claim EOB Tool and ERA/EFT.

This webinar is offered the third Thursday of every

month at 2 p.m. ET.

Precertification

This 45-minute webinar is key for anyone managing the

precertification process for their practice or facility. We

review the Precertification Code Search Tool and show you

how to handle inpatient, outpatient and behavioral health

precertification. We also highlight the precertification inquiry

and precertification status update tools.

This webinar is offered the second Tuesday of every

month at 2 p.m. ET.

Register today

Send an email to [email protected]. In the

subject line, insert the name of the webinar you would like to

attend. In the body of your email, include:

• Webinar name and date

• Tax identification number (TIN)

• Practice name

• Attendee name

• Attendee email address

You’ll get a confirmation email from us that will include a

WebEx presentation invitation.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

©2016 Aetna Inc. 83.03.844.1 (11/16)

www.aetna.com

Learn how easy it is to work with us electronicallyEvery month, our Provider eSolutions team offers live webinars with the opportunity for you to ask questions. Sign up for one of our webinars to learn how to use our self-service tools and to work efficiently and effectively with us.