Of f iceLink Updates™Find updates on important changes to plans and

procedures, drug lists, Medicare and state-specific information. June 2020

Inside thisissue90-day notices

Important reminders

News for you

Pharmacy updates

State-specific updates

Medicare updates

90-day notices and important reminders We’re required to notify you of any change that could

affect you either financially or administratively at least

90 days before the effective date of the change. This

change may not be considered a material change in

all states.

Accurate claims processing with

our Third Party Claim and Code

Review Program Beginning September 1, 2020, you may see new claims

edits. These are part of our Third Party Claim and Code

Review Program. These edits support our continuing

effort to process claims accurately. You can view these

edits on our provider website. We will also begin to

apply Third Party Claim and Code Review Program

edits to Medicare claims in a phased approach.

1

You’ll have access to our prospective claims editing disclosure tool. To find out if our new claims edits

will apply to your claim, log in to the provider website. Then, go to Aetna Payer Space > Resources >

Expanded claim edits. You’ll need to know your Aetna Provider ID Number (PIN).

Note: This is subject to regulatory review and separate notification in Washington state.

National Precertification List

Important NPL update

Effective September 1, 2020, the following precertification changes apply:

• We’ll require precertification for the following drugs:

• Eligard® (leuprolide acetate)

• Firmagon® (degarelix)

• Lupron Depot® (leuprolide acetate)

• Rituxan Hycela® (rituximab/hyaluronidase human)

• Sandostatin® LAR (octreotide acetate)

• Signifor® (pasireotide)

• Somavert® (pegvisomant)

• Trelstar® (triptorelin pamoate)

• Zoladex® (goserelin acetate)

• We’ll require precertification for both the drug and site of care for the following drugs:

• Cinqair® (reslizumab)

• Fasenra® (benralizumab)

• Nucala® (mepolizumab)

• Xolair® (omalizumab)

The following new-to-market drugs require precertification:

• Ziextenzo® (pegfilgrastim-bmez) — precertification required, effective February 1, 2020. This drug

is included in the granulocyte colony-stimulating factor category.

• Adakveo® (crizanlizumab-tmca) — precertification for both the drug and site of care required,

effective February 13, 2020.

• Reblozyl® (luspatercept-aamt) — precertification required, effective February 13, 2020.

• AscenivTM (immune globulin intravenous, human — slra) — precertification for both the drug and

site of care required, effective March 1, 2020.

• Vyondys 53® (golodirsen) — precertification for both the drug and site of care required, effective

March 10, 2020.

• Enhertu® (fam-trastuzumab deruxtecan-nxki) — precertification required, effective March 24,

2020. This drug is included in the HER2 receptor targeted drug category.

• PadcevTM (enfortumab vedotin-ejfv) — precertification required, effective March 24, 2020.

2

• BonsityTM (teriparatide) — precertification required, effective May 1, 2020. This drug is included in

the osteoporosis drug category.

Effective April 1, 2020, the following new-to-market drugs will require precertification:

• Esperoct® (antihemophilic factor [recombinant], glycopegylated-exei)

• OgivriTM (trastuzumab-dkst)

• RuxienceTM (rituximab-pvvr)

• TrazimeraTM (trastuzumab-qyyp)

• VumerityTM (diroximel fumarate)

We encourage you to submit precertification requests at least two weeks before the scheduled

services.

To save time, request precertification electronically — it’s fast and simple. Most precertification requests

can be submitted electronically through the provider website or by using your Electronic Medical Record

(EMR) system portal.

You can find more information about precertification under the “General Information” section of the

NPL.

Claim editing enhancements for medical specialty pharmacy

Beginning September 1, 2020, we’ll enhance our daily unit-limit claim editing for medical specialty drugs

for our Medicare members. We’ll use a phased approach, and we’ll apply diagnostic and member

characteristics (age, diagnosis, gender, etc.) to determine the specialty drugs’ qua ntity limits. You may

see temporary differences in this population’s claims adjudication across the Medicare Advantage

programs.

This enhancement is a part of the new Novologix® online prior authorization system. We began applying

this editing to our commercial members on March 1, 2020.

Allowable non-emergent basic life support transport services

Non-Emergent Basic Life Support Ground Ambulance Transport Services, identified by HCPC A0428, will

only be allowed when it’s the only way to safely and adequately transport the patient and when other

means of transport are unsafe due to the medical condition of the patient.

Examples of when we’ll allow the non-emergent basic life support code A0428 are when the patient:

• Has a bed confinement status

• Needs continuous supervision

• Has other reduced mobility

• Requires physical restraint

• Is dependent on enabling machines and devices

3

• Is being transported from one hospital to another or from a hospital to a skilled nursing facility and

back

As of September 1, 2020, we will no longer cover any non-emergent basic life support transport service

for routine care, patient convenience or non-emergency reasons, unless a prior authorization is

submitted and approved.

Changes to commercial drug lists begin on October 1, 2020

On October 1, we’ll update our pharmacy drug lists.

You’ll be able to view the changes as early as August 1. They’ll be available then on our Formularies &

Pharmacy Clinical Policy Bulletins page.

Ways to request a drug prior authorization

• Submit your completed request form through our provider website.

• Fax your completed prior authorization request form to 1-877-269-9916.

• If you have a request for a nonspecialty drug, call the Aetna Pharmacy Precertification Unit at 1­

855-240-0535 (TTY: 711).

• If you have a request for a drug on the Aetna Specialty Drug List, call the Aetna Pharmacy

Precertification Unit at 1-866-814-5506.

These changes will affect all Pharmacy Management drug lists, precertification, quantity limits and step­

therapy programs.

For more information, call the Aetna Pharmacy Management Provider Help Line at 1-800-238-6279 (1­

800-AETNA RX) (TTY: 711).

Important reminders Diagnosis-related group (DRG)

readmission payment policy

As a reminder of our readmissions payment policy: This

policy applies to both Commercial and Medicare

Advantage products. This policy applies to participating

acute care facilities contracted with DRG rates.

We will not recognize and reimburse another DRG for members who are readmitted to the same facility

for symptoms related to, or for the evaluation and management of, the prior stay’s medical condition

4

within 30 calendar days. The subsequent admission is considered to be included in the DRG from the

initial admission.

The following types of admissions are excluded from this policy:

• Readmissions unrelated to the initial admission

• Planned readmissions

• Readmissions due to an unavoidable complication

• Readmissions after the member left the facility against medical advice (AMA) for the initial

admission

Select oncology medications are being added to the Site of Care

management program

Aetna supports efforts, where medically appropriate, to treat patients at nonhospital facilities or in the

comfort of their home. We appreciate this effort now more than ever to slow transmission of SARS-CoV­

2 through methods such as social distancing and reducing contact with patients who potentially have

COVID-19. The CDC has provided guidance for health care facilities to 1) provide the ap propriate level of

necessary medical care, 2) protect health care personnel and non-COVID-19 patients from infection, 3)

prepare for a potential surge in patients with respiratory infection and 4) prepare for Personal Protective

Equipment (PPE) and staffing shortages. See CDC guidance.

In alignment with these goals, during and after COVID-19, we are adding and will continue to add

additional medications to our Site of Care process starting July 1, 2020. The Site of Care policy provides

criteria to determine the medical necessity of hospital outpatient administration as the site of service for

identified specialty medications.

This change applies to members in commercial plans who receive a renewal authorization for the below

specialty medications, to continue maintenance monotherapy. This change does not apply to Medicare

or Medicaid members.

Which specialty drugs are affected?

This policy change applies to the following infusions administered by health care professionals when

administered as monotherapy for maintenance: nivolumab (Opdivo®), pembrolizumab (Keytruda),

ipilimumab (Yervoy®), durvalumab (Imfinzi durvalumab), cemiplimab (LibtayoTM), avelumab (Bavencio®)

and atezolizumab (Tecentriq®).

The initial combination therapy regimens for medications subject to this policy may be given at the

physician’s facility of choice. All subsequent doses for maintenance monotherapy will be subject to the

Aetna Site of Care for Drug Administration policy, which requires the use of nonhospital outpatient

facilities for administration. Members that fulfill Aetna’s Site of Care medical necessity criteria will be

allowed to continue infusions in the outpatient hospital.

Safety

These medications are commonly administered in outpatient community physician practices, not in

hospital-based outpatient facilities. The administration of checkpoint inhibitors is associated with less

toxicity compared to other medications that are infused in the same practice setting. T he side effects

5

associated with these medications develop over time because of their immune medicated mechanism.

Infusion reactions are a common concern when transitioning patients to an alternate site of care. Severe

or life-threatening reactions have occurred in less than 2 percent of patients receiving these

medications. Infusion reactions (all grades) have been reported in less than 10 percent of patients

receiving the approved checkpoint inhibitors, except avelumab, in which reactions are reported in 2 5

percent of patients.

Costs and coordination

Costs for these medications, when administered in the outpatient hospital, often may exceed $20,000

per infusion. Savings associated with non-hospital-based administration or specialty-pharmacy-provided

medication may exceed 50 percent.

Members and providers may choose in-network options, including using independent infusion centers

and home infusion, or the medication may be administered in the physician’s office. When this is not

possible, Aetna can coordinate with the facility to deliver patient-specific medication from a specialty

pharmacy. Aetna’s specialized team of infusion consultants will help identify the best option for

members and their health care providers.

We’re here to help

If you have questions about this policy, please contact us.

Thank you in advance for your cooperation.

Procedures/services on the National Precertification List (NPL)

Precertification occurs before inpatient admissions and select ambulatory procedures and services.

Precertification applies to all:

• Procedures and services on the Aetna Participating Provider Precertification List

• Procedures and services on the Aetna Behavioral Health Precertification List

• Procedures and services that require precertification under the terms of a member’s plan

• Organization determinations made by a Medicare Advantage member, appointed representative

or physician for a coverage decision

You should also be sure to precertify any procedures or services on the Aetna Provider Precertification List that an Aetna® member receives during an inpatient confinement. Refer to Aetna.com for more information.

We’ve enhanced our claims editing process

Our claims system makes edits to complex claim scenarios to make sure coding and modifier usage

aligns with industry guidelines. For example, we evaluate the appropriate use of separate and distinct

service modifiers, as well as the separately identifiable evaluation and management modifiers.

6

If the coding edit doesn’t apply to the services performed, you have a right to request a

reconsideration/appeal. Just include supporting information, such as the medical records, along with the

reason you find the edit doesn’t apply.

When it’s appropriate, we evaluate claims against:

• Internal coding guidelines

• The Centers for Medicare & Medicaid Services medical coverage, payment and coding policies

• The American Medical Association Current Procedural Terminology® (CPT®) coding standards

Reminder — experimental and investigational labs

We consider certain laboratory tests to be experimental and investigational. These noncovered

laboratory tests are not covered by most of our plans. This means your patient may be responsible for

the full cost of these laboratory tests.

There are several tests that Aetna® may not cover, but the most common are:

• Lyme Disease (CPB #0215)

• Vitamin D Assay (CPB #0945)

• Lipoprotein Cholesterol Test (CPB #0381)

• Homocysteine Test (CPB #0381)

Information you should share with patients

It is important that your patients understand that they are financially responsible for these tests, as they

are noncovered services. Please remind your patients at the time you order the test that they are

responsible for the full cost of laboratory tests.

CPT code 92586 and newborn hearing test — a technical-only code

CPT code 92586 is a technical-only code (CMS guidelines and Aetna policy) and, as such, can and should

be billed only by the hospital/facility and not a third party. Under your network contact, payment for

this newborn hearing test is included in the global code we pay to the hospital, and any claims received

by a third party that is subcontracted by the hospital for this service will be denied.

If your hospital/facility is outsourcing this service to third party providers (whether or not they bring

their own equipment into the hospital/facility and perform the test), payment to the third party is the

responsibility of the hospital/facility and not Aetna or Aetna® plan sponsors or members. The hospital

should immediately advise its third party providers not to bill Aetna or the patient/member(s) for this

service; payment for this service to any subcontracted third party provider is to be the responsibility of

the hospital/facility, and any equipment and/or services provided by an alternate facility and or

vendor/provider during the course of an admission or procedure is the financial responsibility of the

Hospital per standard coding guidelines.

7

We are respectfully requesting that you immediately

advise any and all vendor/provider(s) you have

subcontracted with for this service of this policy.

News for you You can still register for the new

Availity® provider portal

We get it. Everyone is trying to work through the changes affecting health care now. And we're right here

to support you. So we're giving you extra time to register on the new Availity provider portal. This will

help ensure you have enough time to transition and avoid any interruptions in your business.

Make sure you’re ready for the move by May 15, 2020

Starting May 16, 2020, you’ll no longer have access to Aetna tools and transactions on NaviNet®. But

rest assured — your free Availity account already delivers what you need. You'll find eligibility and

benefits records, claims, authorization and referral info, and more.

Haven’t begun the registration process for your organization yet? No worries. Just visit our site to learn

how to register and get started.

Get ready with free training

Check your calendar and join us for a free Availity webinar or virtual event. We'll show you all the

shortcuts you need to transition to Availity. Enroll today!

Better health outcomes for substance use disorders

Patients with alcohol and substance use disorders are more likely to have better outcomes with patient

education, early treatment and follow-up care. You can make a difference. Schedule follow-up treatment

each time you diagnose a new episode of alcohol or other drug (AOD) dependence.

Improving outcomes • Screen your patients for at-risk alcohol and substance use. You can be reimbursed for this

screening.

• Educate your patients about their diagnosis.

• Discuss the importance of follow-up care and attending all appointments.

• Involve your patients’ support system and help those supporters understand how they can help.

Managing appointments for success

• Schedule the initial AOD dependence treatment within 14 days of diagnosis. Treatment may

include:

o Telehealth or medication-assisted treatment (MAT)

o An outpatient visit

o An intensive outpatient visit

8

o Inpatient admission

o Partial hospitalization

• Arrange two additional visits within 34 days of the initial visit.

• Use appropriate diagnosis codes.

• Use the diagnosis of AOD judiciously. For example, if your adolescent patient receives an AOD

dependence diagnosis, they should receive follow-up treatment.

• Ensure that all claims contain place of service, procedure code (as applicable to your contract)

and AOD dependence diagnosis.

Referring patients to a behavioral health professional

We’re here to support the care you give your patients. Call the member service number on the patient’s

ID card. We can help connect your patient with a behavioral health provider.

Antidepressant adherence tool kit Depression responds remarkably to antidepressant therapy. However, many patients are reluctant to

take antidepressants, creating very high rates of nonadherence. Those who adhere to therapy early and

continue to take medication as prescribed are more likely to recover from depression and avoid future

relapse.1

You can help improve adherence

Using the depression medication decision choice aid can help you work with your patients to select

the right medication for them. This can lead to an increase in medication adherence and improve quality

outcomes for them.

Failure to adhere to therapy leads to several high-risk outcomes2 such as poor quality of life,

comorbidity-related death and suicide attempts. These can affect patients who:

• Don’t take their medicine during the first six weeks of therapy

• Have chronic conditions such as chronic obstructive pulmonary disease, diabetes, heart diseases

and myocardial infarction

Learn more by reading these depression resources for clinicians.

1Meyers BS, Siren JA, Bruce M, et al. Predictors of early recovery from major depression among persons admitted to community -based clinics:

an observational study. Arch Gen Psychiatry. 2002; 59(8): 729–735. 1Ho SC, Jacob SA, Tangiisuran B. Barriersand facilitators of adherence to antidepressants among outpatientswith major depressive disorder: a

qualitative study. PLoS One. June 14, 2017; 12(6): e0179290. doi:10.1371/journal.pone.0179290.

1Meyers BS, Siren JA, Bruce M, et al. Predictors of early recovery from major depression among persons admitted to community-based clinics:

an observational study. Arch Gen Psychiatry. 2002; 59(8): 729–735. 2Ho SC, Jacob SA, Tangiisuran B. Barriersand facilitators of adherence to antidepressants among outpatientswith major depressive disorder: a

qualitative study. PLoS One. June 14, 2017; 12(6): e0179290. doi:10.1371/journal.pone.0179290.

9

Your patients deserve a provider directory they can count onIt is vital that your patients can find you when they need care. To this end, Aetna uses vendors to collect

your data and ensure that our provider directories are accurate. We use Availity® and CAQH® as the

primary source to update your data.

By verifying your most current information, patients can easily see your network participation, office

hours or just your address. You can help ease the burden on your patients by ensuring that your

information is correct and up to date.

If you need to make a change, go to Availity and CAQH to update your data.

Check your information each quarter

Even if nothing has changed, it is important to attest to the accuracy of your data each quarter.

Update NPPES data too

The Centers for Medicare & Medicaid Services (CMS) suggests using the National Plan and Provider

Enumeration System (NPPES) to review, update and attest to your NPPES data. We join with CMS to

remind providers to keep their data up to date. Accurate provider directories help Medicare members

find providers and make health plan choices.

Make sure patients can find you

Keep your data updated to avoid losing patients and to reduce the number of calls, letters and emails

you get from us. If you fail to review and attest to your data in Availity or CAQH, we may need to remove you

from the directory.

Important message for Massachusetts providers

In November 2018, we expanded our relationship with CAQH to improve our provider directory

accuracy. This expanded relationship was necessary to address guidance from both the Commonwealth

of Massachusetts and the Centers for Medicare & Medicaid Services (CMS). Massachusetts commercial

and Medicare providers are asked to validate their demographic information quarterly in CAQH. This

process helps us improve the accuracy of our Massachusetts provider directories. We appreciate your

cooperation with this program.

Avoid delays with your precertification request

To avoid delays, note the following:

• Do not start a precertification request until all necessary clinical information is available for

submission.

• Always include reference number, patient name and insurance ID number on all clinical

information submitted.

• If submitting by telephone, fax the requested clinical information to the provided fax number.

• If submitting electronically — our preferred method for submission — upload clinical information

when accessible.

Remember, reviews cannot be completed without receiving necessary clinical information.

10

Failure to submit clinical information can result in a denial.

Follow-up care for ADHD

Managing attention-deficit/hyperactivity disorder (ADHD) doesn’t end with a medication and treatment

plan. Talk with your patients about the importance of follow-up care. Here we offer some tips.

Medication follow-ups

The American Academy of Pediatrics recommends that physicians who prescribe medication for

ADHD:

• Schedule an in-person follow-up visit with the patient 30 days after the initial prescription

• Schedule two more follow-up visits after the initial visit — these visits are to review and check

how the child is doing and look for any side effects

• Schedule monthly visits, if needed, until a good routine is in place

• Schedule visits every three months for the first year

Track progress

Treatment plans for ADHD often involve medications plus behavior therapy and everyday support

strategies. Using a mix of these actions can promote calmer relationships with family members, better

study habits and more independence. Parents can track their child’s progress with report cards. There

are also several apps that may help.

Support for patients and parents

You may want to encourage your patients (and their parents) to seek more help from:

• A support group

• Parent training program

• Counseling

• Stress-management techniques

We enhanced

our

precertification

inquiry

responses to

give

you

more than

just “pended”

You told us you wanted more details when we pend a precertification request. Now we’ll include specific

details and expected turnaround times. Here are two examples with the new details included:

• Pending with Medical Director for Review. Decision will be made within 72 hours of the receipt of

the request.

• Pending with Clinical or Nurse for Review. Decision will be made within 72 hours of the receipt of

the request.

The messages will change as the request moves through our systems. You can see these enhanced

responses when you submit an electronic precertification inquiry on your vendor’s website, even if the

original request wasn’t submitted electronically.

Not currently using a provider portal? Use our Availity® provider portal to submit requests or upload clinical information and forms. Read more about the Availity provider portal and how to register.

11

Help improve communication between treating providers

A recent survey showed that primary care physicians (PCPs) are concerned because they don’t

get regular reports about their patients’ ongoing evaluation and care from other treating

providers.*

This breakdown in communication can pose a threat to quality patient care. We know that

coordinating care with many physicians, facilities and behavioral health care professionals can

be a challenge. Thank you for your efforts to improve communications.

Use our tools to share information

Talking with your patients’ other treating health care professionals helps you give them the

best care. To promote collaboration and comprehensive care, it’s critical that PCPs and

specialists talk openly with each other.

You can use our tools to help. Go to Aetna.com to find them. Click on “Providers” on the home page.

Then click “Find a form.” Scroll down until you see “Physician communications.” Here are quick links for

you:

• Dilated Retinal Eye Examination Report Form

• Physician Communication Form

• Physician Communication Post-Fragility Fracture Care Form

• Specialist Consultation Report

*Each year we survey primary care practices contracted for all Aetna products.The surveys assess the

practices’ attitudes and perceptions on key interactions with us.We use the Center for the Studies of

Services, a third-party vendor, to administer the surveys.They perform the surveys at market levels

accredited by the National Committee for Quality Assurance.

Our office manual keeps you informed

Our

Office

Manual

for H

ealth

Care

Professionals

is

available

on

our

website.

For

Innovation

Health,

once

on

the

website,

select

“Health

Care

Professionals.”

Visit

us online

to

view a

copy of

your p

rovider

manual

(if

you

don’t

have

Internet

access,

call

our

Provider

Service

Center

for

a

paper

copy)

as

well

as

information

on

the

following:

• Policies and procedures

• Patient management and acute care

• Our complex case management program and how to refer members

• Additional health management programs, including disease

management, the Aetna Maternity Program, Healthy Lifestyle Coaching and others

12

• Member rights and responsibilities

• How we make utilization management decisions, which are based on coverage and appropriateness

of care, and include our policy against financial compensation for denials of coverage

• Medical Record Criteria, which is a detailed list of elements we require to be documented in a

patient’s medical record and is available in the Office Manual for Health Care Professionals.

• The most up-to-date Aetna Medicare Preferred Drug Lists, Commercial (non-Medicare)

Preferred Drug Lists and Consumer Business Preferred Drug List, also known as our formularies.

Our medical directors are available 24 hours a day for specific utilization management issues. Contact us

by visiting our website, calling Provider Services at 1-800-624-0756 (TTY: 711) or calling patient

management and precertification staff using the Member Services number on the member’s ID card.

Visit us online for information on how our quality management program can help you and your patients.

We integrate quality management and metrics into all that we do, and we encourage you to take a look

at the program goals.

Learn about changes to our client’s branding

The new brand for our Aetna Signature Administrators® client, Trustmark®, unites its family of

companies under one brand umbrella.

• The Starmark brand, which was retired in October, has moved to a new brand: Trustmark Small

Business Benefits®.

• In January, the legal name CoreSource, a subsidiary of Trustmark, changed to Trustmark Health

Benefits, Inc.

Look for this new branding on ID cards and other communications.

Preeclampsia in pregnancy

Aetna is launching a new initiative to educate members about preeclampsia in pregnancy and the role of

low-dose aspirin for prevention, as recommended by multiple medical professional societies.

We mail information created by the Society for Maternal Fetal Medicine to pregnant women in the Aetna

Maternity Program. If any of these women are identified through claims data as having risk factors for

preeclampsia, they will receive two additional things: 1) a kit containing additional educational

information to refer to during their next prenatal office or telephonic visit and 2) low-dose aspirin.

Members are encouraged to talk to their physicians about preeclampsia prevention and whether low ­

dose aspirin is appropriate for them.

Documentation and coding tips

It’s important to follow the International Classification of Diseases, Tenth Revision (ICD-10) guidelines. Doing so

helps to ensure that you are coding conditions properly. Here are some important tips.

13

1. Remain consistent throughout the medical record

• Stay the course and remain consistent

• Avoid templates and prefilled “normal” values

2. Use the M.E.A.T. concept to document patients’ conditions

• Monitor signs, symptoms, disease progression, disease regression

• Evaluate test results, medication effectiveness, response to treatment

• Assess/Address ordering tests, discussion, review records, counseling

• Treat using medications, therapies, other modalities

3. Update medication lists; link medications to the conditions they are being used to treat

A complete medication list should have: • A clear description of name of medication and dosage prescribed• An indication of whether a medication is current or discontinued• A diagnosis for which each medication is prescribed• The date the medication list was updated

We offer a number of educational opportunities on this topic. Contact us at RiskAdjustment@aetna.com for more information.

Pharmacy updates Formulary information at your

fingertips

Want to select a preferred drug for your patient from

your cell phone? It’s fast and easy. You can access our

commercial formulary on your mobile devices. Just go

to the Google Play™ store* and type in “formulary

14

 

 

 

  

 

   

search” — then download the Formulary Search app for free.

You can also search at FormularyLookup.com. Enter the drug name, state and channel (plan type).

Then, under “Payer/PBM,” select “Aetna Inc.” to view the drug coverage information. At the bottom of the

page, you can also select “Download on the App Store” to access this information on your phone.

*Google Play and the Google Play logo are trademarks of Google Inc. App Store is a service mark of

Apple Inc. registered in the U.S. and other countries.

Important pharmacy updates

Medicare

Visit our Medicare drug list web page to view the most current Medicare plan formularies (drug lists).

We update these lists at least once a year.

Commercial — notice of changes to prior authorization requirements

Visit our Formularies & Pharmacy Clinical Policy Bulletins web page to view:  

• Commercial pharmacy plan drug guides with new-to-market drugs that we add monthly

• Clinical Policy Bulletins with the most current prior authorization requirements for each drug

State-specif ic updates Here you’ll find state-specific updates on policies and regulations.

Arkansas Updates - Notice of

material amendment to healthcare

contract Arkansas providers, the articles published in this

edition are your notice of Material Amendment to Healthcare Contract. It is being sent pursuant to Ark.

Code Ann. § 23-99-1205(a) and shall apply to all Provider, Physician, Ancillary, Facility and Hospital

healthcare contract(s).

15

 

California updates

How to access your fee schedule: In accordance with the regulations issued pursuant to the Claims Settlement Practices and Dispute

Mechanism Act of 2000 (CA AB1455 for HMO) and to the expansion of the Health Care Providers Bill of

Rights (under CA SB 634 for indemnity and PPO products), we’re providing you with information about

how to access your fee schedule.

• If you’re affiliated with an Independent Practice Association (IPA), contact your IPA for a copy of your

fee schedule.

• If you’re directly contracted with Aetna, you can call our Provider Service Center for help with up to ten

Current Procedural Terminology® (CPT®) codes. For requests of eleven or more codes, you can enter

the codes on an Excel spreadsheet (include tax ID, contact telephone number, CPT codes and modifier)

and email them to us at feeschedule@aetna.com.

• If your hospital is reimbursed through Medicare Groupers, visit the Medicare website for your fee

schedule information.

Colorado updates

Notice of material change to contract For important information that may affect your payment, compensation or administrative procedures,

see the following articles in this edition:

• Updates to our National Precertification List

• Clinical payment and coding policy changes

Illinois updates

New administrator for IL Park District Risk Management

Association (PDRMA) HealthSmart is the new administrator for Illinois' Park District Risk Management Association (PDRMA),

accessing the Aetna network through the Aetna Signature Administrators (ASA) solution. Please send all

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

Refer to the ASA provider flyer for additional information on claims submissions.

New Jersey updates

Where to find our appeal process forms? We have updated the information about internal and external provider appeal processes on our public

website.

16

If you use the NJ Health Care Provider Application to Appeal a Claims Determination form when

submitting certain claims appeals, you should make sure your claim is eligible. You can find this form

and the correct procedures on our public website.

Pennsylvania updates

Guidance about PEBTF’s lab benefit

You may get questions about Aetna lab services offered through the Pennsylvania Employees Benefit

Trust Fund (PEBTF).

Here’s a helpful lab coverage chart comparing active and Retired Employees Health Program (REHP)

patients. Refer to the member’s Aetna ID card for the plan name and to the chart below for the cost

share.

PEBTF Custom HMO

Covered 100% at any custom

in-network lab

PEBTF Open Choice PPO

Covered 100% at Quest

Diagnostics® and LabCorp

$30 copay at other in-network

labs

REHP Aetna MedicareSM Plan

(PPO)

(Medicare Open Access PPO)

Covered 100% at any lab

Read the full article.

Questions about other b enefits?

Just call our Provider Contact Center at 1-800-624-0756, Monday through Friday, 8 AM to 5 PM local time.

Washington updates

Referrals are not required for Medicare Advantage HMO members

As of January 1, 2020, all Aetna Medicare Advantage health maintenance organization (HMO) members

in Washington have direct access to in-network Medicare HMO network providers. We no longer require

primary care providers to submit referral requests to us. Members no longer need referrals to see

specialists; however, precertification requirements still apply.

Some specialists may ask for a referral from the referring provider before scheduling an appointment

for a member. If that happens, you can coordinate that process between the referring provider and the

specialist, since it’s no longer an Aetna requirement.

We’re here to help

Have questions about this? Our Provider Contact Center team is here for you. Just call

1-800-624-0756 (TTY: 711).

17

Medicare updates Get Medicare-related information, reminders and guidelines.

Don’t let your network status

change — complete your Medicare

compliance training to comply

with CMS requirements

If you are a participating provider (individual, group, facility or ancillary, etc.) in our Medicare Advantage

(MA) plans, Medicare-Medicaid plans (MMPs) and/or Dual Special Needs Plans (DSNPs), you must meet

the Centers for Medicare & Medicaid Services (CMS) compliance program requirements for first-tier,

downstream and related (FDR) entities and/or the DSNP Model of Care (MOC) training and attest to that

training by December 31, 2020.

How to complete your attestation

The Medicare FDR and MOC attestation(s) will be released in second quarter of 2020. You’ll find the

attestation and training resources you need to ensure your compliance on Aetna.com under “Need

More Information on the Medicare FDR Program” section. For dually contracted MA and DSNP providers,

we’ve combined the DSNP MOC and FDR attestations so that you need to complete only one.

Where to get more information

If you have attestation-completion or compliance-related questions, please review all supporting

materials published on our Aetna.com/medicare site. Just email us at FDRAttestation@aetna.com if

you don’t find the answers you need. Email us at Medicaidmmpfdr@aetna.com if you’re an MMP-only

provider. You’ll find more information in our quarterly FDR Compliance Newsletter, too.

18

© 2020 Aetna Inc.

83.03.877.1 (06/20)