10/31/2016 · 10/31/2016 2 4 meritain health, an aetna company quick overview sample id card a...
TRANSCRIPT
10/31/2016
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DOING
BUSINESS WITH
AETNA
&
COFINIT Y1
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RECONTRACTING-Separate agreements.
-Separate networks.
- Aetna is a Payer, Cofinity is a Network Access Agreement.
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Aetna Medicare AdvantageEmployer Based Plan.
- PPO Product.
- Physician Services Based on Medicare Reimbursement.
- Follows Aetna coding and guidelines.
Aetna Behavioral Health-Separate agreements.
-Separate networks.
- Adding a new Behavioral Health Provider, visit www.Aetna.com / Health Care Providers / Join the Network / Select Behavioral Health Applications
- Aetna Behavioral Health Customer Service: 1-888-632-3862
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MERITAIN HEALTH, AN AETNA COMPANY
QUICK OVERVIEW Sample ID card
A guide for doing business with Meritain Health Contracts
Since Meritain Health is a fully owned Aetna subsidiary, if contract includes
PPO or Choice POS II products, then your contract also applies to Meritain
Health patients who have elected the Aetna network. Please note that
Meritain is no longer a part of Aetna Signature Administrators®.
Recognizing a Meritain member
To identify a patient who is using the Aetna network through Meritain, look
for the Meritain logo and “network by Aetna” on the patient’s member ID
card.
Meritain does work with other networks. If an employer selects a network
other than Aetna for their employees, Meritain will follow the rules
governing those network contracts.
Aetna’s responsibility
• Handle claims pricing
• Provide network access services and management
• Resolve provider contract issues
Meritain’s responsibility
• Handle claims processing
• Provide customer service
• Conduct utilization review to determine medical necessity based
upon Aetna Clinical Policy Bulletins (criteria)
If you don’t have access to the website or ID card, call 1-800-925-2272.
www.meritain.com
OPTIONS AVAILABLE WITHOUT LOGIN
AETNA’S HEALTH CARE PROFESSIONALS WEBSITE
www.aetna.com
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PROVIDER DEMOGRAPHIC REQUESTS
INCLUDE:New Provider Enrollments
Is your new Provider already participating in the Aetna/Cofinity Network? Find out at:
Aetna Provider Services 888-632-3862
Cofinity Customer Service 800-831-1166
If not, contact Aetna Credentialing at 800-353-1232 to determine the provider’s Aetna credentialing status.
Updates to Current Providers
Do you have changes to your Practice address, Tax ID, or New Patient Status?
Need to submit a Provider Termination from your Practice?
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SUBMIT DEMOGRAPHIC CHANGES
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Aetna: Via below form at aetna.com (under “Healthcare Professionals” and then “Helpful Links”) or via NaviNet by Security Officer
Cofinity: Via website or send directly to [email protected]
Please allow 30-45 days for Aetna’s and Cofinity’s Provider Data Service
Teams to process Provider maintenance requests.
NEW PROVIDER ENROLLMENTS
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Provider IS credentialed by Aetna to participate but is not currently tied to
your Practice Tax ID.
Aetna Direct Groups >NaviNet –NaviNet Security Officer transaction or>www.aetna.com Health Care Professionals Update Provider Demographic Data Submit or >Fax Letter to Provider Data Maintenance at 859-455-8650
Cofinity Network Groups>www.cofinity.net Find by Customer Provider Contact Us or>Email Provider Add request to [email protected] or>Contact Cofinity Customer Service by phone at 800-831-1166
Provider is NOT currently credentialed by Aetna to
participate.
Aetna performs credentialing for Aetna and Cofinity Network Participation.>www.aetna.com Health Care Professionals Join the Network Submit or>Contact Aetna Credentialing by Phone at 800-353-1232
You will need to select: Medical, Dental, or Behavioral
• If Medical then 2 options: Mid-level (Non-credentialed) or All Other
(Credentialed)
• Provide all Demographic Details: including CAQH #, TIN (if joining a par
tin must use group tin), email, NPI, License #, if PCP/Spec and more
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AETNA CREDENTIALING FAQs
1. I've heard of an organization called the Council for Affordable Quality Healthcare or CAQH. Can you tell me more about this organization?
Answer: Yes, CAQH is a nonprofit alliance of America’s leading health plans allowing providers to submit one application to meet the needs of all of the health plans and hospitals.
2. If I am already registered with CAQH, what are my next steps?
Answer: Please ensure that you have granted Aetna authorization to review your information.
3. If I have not yet registered with CAQH, what are my next steps?
Answer: If you have not completed CAQH’s online registration, you will receive a registration kit from CAQH within 7-10 business days after submitting your online application.
4. How long does the credentialing process take?
Answer: The credentialing process takes approximately 90-days post application submission date. You may check status of your application by contacting our Aetna Credentialing Department at 800-353-1232.
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‹#›
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PROVIDER SERVICE CENTER: 1-888-632-3862
Aetna Medicare Service Center: 1-800-624-0756
Aetna Credentialing: 800-353-1232
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‹#›
‹#›
ENTER AETNA HEALTH PLAN
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Look for Access /
Security Officer FAQs
and Tips
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‹#›
AETNA PLAN CENTRAL
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Left: Aetna Secure Options Center: Check Important Announcements Right: Links to Provider Resources
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CONTACT AETNA
PROVIDER SERVICES
DIRECTLY ONLINE
Example:
• Select Support Center / Doing Business
With Us – see many informational links
• At Bottom of most screens in Grey Box
• Under Tools
• Select “Contact”
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“CONTACT US” FEATURE
NaviNet – Look for a gray shaded “Contact” link in the lower portion of the screen.
Benefits of using the “Contact” feature include: • Dedicated staff committed solely to managing requests directed to Aetna through the
“Contact” feature.
• Estimated Turnaround Time for response varies by the complexity of your inquiry but you WILL get a response.
• Reconsideration option drives the claim back through the auto-adjudication process.
• Eliminates the need to contact the Aetna Service Center via phone.
• You will provide your own direct name, TIN or NPI, email and phone for response.
• For member type inquires (options 1-5) will need to select Traditional plan (W ID#’s) or HMO for Aetna Medicare, also will need Member ID number and Group number.
Currently there is an inability to upload attachments with this feature, i.e. medical records, clinical notes, etc. Aetna is researching enhancements.
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ELIGIBILITY
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ELIGIBILITY DETAILS
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This box shows Product & COB Details
Click here to view &
Print ID Card
WHAT’S NEW?
ACCESSING ONLINE MEMBER ID CARDS
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Digital Member IDsPlease remember - if an Aetna Patient shows you a digital or printed copy of their ID, you should accept it as valid proof of coverage.
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PAYMENT ESTIMATOR / REQUEST SCREEN
Choose one
Type of estimate
Billing provider
Place of service
Diagnosis code(s)
Procedure code(s)
Billed Charge
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SEE ALLOWED FEES, PT. RESP., REDUCTIONS
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REFERRALS
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REFERRAL FORM
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REFERRAL INQUIRY
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PRECERTIFICATION
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PRECERTIFICATION
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PRECERTIFICATION FORM
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PRECERTIFICATION
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PRECERTIFICATION CODE SEARCH TOOL
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ACCESS CLAIM PAYMENT & CODING POLICIES
SELECT SUPPORT CENTER / CLAIMS
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ACCESS WRITTEN PRICING POLICIES
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ALPHABETICAL LIST
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CLICK TO REVIEW AND PRINT
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ACCESS EOB’S
RECOMMEND SEARCHING BY PATIENT
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SUBMIT CLAIMS FOR RECONSIDERATION ONLINEGO TO CLIAM EOB TOOL / EOB SEARCHPOPULATES CLAIM DATA
ONLY RUNS BACK THROUGH SYSTEM (I.E. USE WHEN PROVIDER PAR STATUS UPDATED,
OR LEVEL 1 APPEAL/RECON)
GENERATES TRACKING NUMBER
RESOLUTION GENERATES NEW EOB
CANNOT SUBMIT NOTES
APPROX. 2-3 WEEK TURNAROUND
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TIN Level
Access
SUBMIT PROJECT REQUESTS (OVER 25 CLAIMS SAME ISSUE)
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• Select Account Management Tools / Multiple Claim Reconsiderations
• Specialized Rep. to identify root cause and correct
• Can submit with just 2 examples, or list all claims
• Can also first request claim history report to get all claim IDs to copy
PROJECTS: APPROX. 45 DAY TURN AROUND
WILL PROVIDE REPORT IF REQUESTED
AND NEW FINANCIAL DETAILS
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MEDICARE ATTESTATION
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• Currently must be completed via NaviNet.
• If PHO / IPA NaviNet currently does not grant access (working on solution
hopefully by end of year)
• For now this year only, these groups can send attest form with a roster / list
of all Tax IDs. Send signed form and tin list to: [email protected]
WILL SHOW IF EXPIRED
Check boxes for steps completed, fill in signature of person attesting
and submit.
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Aetna Dispute/Appeals process is summarized on aetna.com
http://www.aetna.com/healthcare-professionals/policies-guidelines/dispute_process.html
First: Claim Reconsideration (or Level 1 appeal)o Submit within 180 days from initial claim decision.
o Aetna has up to 60 days to review and respond.
Next: Level II appeal must by filed within 60 days of the reconsideration or Level 1 response
1-800-624-0756 for HMO-based benefits plans
1-888-632-3862 for Indemnity and PPO-based benefits plans
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AETNA DISPUTE AND APPEALS PROCESSMail Appeal letter and records or supporting documents to:
Aetna Provider Resolution Team
P.O. Box 14020 Lexington, KY 40512
Fax: 1-859-455-8650
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RADIOLOGY PRE-AUTHORIZATION
Med Solutions (DBA eviCore Healthcare or MSI) is responsible for the preauthorization of high-tech outpatient diagnostic imaging procedures for Aetna members.
Preauthorization is required for CT scans, Nuclear cardiology, MRI/MRA, PET scans, Sleep Studies and select cardiac imaging services.
Preauthorization can be completed by calling MSI at (888) 693-3211 or online at www.MedSolutionsOnline.com or FAX (888) 693-3210.
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AETNA EFT/ERA
-Paper-free. The EFT/ERA enrollment is now
standard for Aetna
-Complete EFT/ERA forms
https://navinet.navimedix.com
Sign Up for EFT Notification Emails on
NaviNet under Email Options
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AETNA OFFICELINK NEWSLETTER
-Quarterly updates.
-Signup on Navinet under Communications / Newsletters or www.aetna.com.
-National Precertification List.
-Clinical Payment, coding and policy changes.
-Changes to preferred drug list.
-Learning opportunities and more.
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LABORATORYQuest Diagnostics® is our national preferred laboratory. It
provides tests and services to all Aetna members.
Find a convenient location, schedule an appointment and get
testing reminders by visiting Quest Diagnostics or calling
1-888-277-8772.
Your market may also have contracted with local laboratory
providers such as:
Michigan
• Joint Venture Hospital Laboratories www.jvhl.org
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AETNA SIGNATURE ADMINISTRATORS (ASA)
• Providers should direct all ASA claim questions to the
appropriate payer on the members card.
• ASA determines benefits and eligibility.
• See logo on ID cards below
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AETNA STUDENT HEALTH (ASH)
• NaviNet support eligibility & benefits, claims status
inquiry, precertification and referral transactions for
members covered under Aetna Student Health plans.
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Cofinity Customer Service
1-800-831-1166
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USING COFINITY’S WEBSITE
Cofinity’s website has many features:
Make claims inquiries
See repriced amounts
Get payer information
Access specialty billing rules
Find in-network providers
Access GH / WC / Auto Participating Payer Lists Updated Quarterly
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COFINITY WEBSITE
View Cofinity’s
updated website at:
www.cofinity.net
for member & claim
inquiry, claim activity
reports, access payer
information, update
provider
demographic
information and other
tools.
View Cofinity’s
updated website at:
www.cofinity.net
for member & claim
inquiry, claim activity
reports, access payer
information, update
provider
demographic
information and other
tools.
COFINITY WEBSITE
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MEMBER CLAIM INQUIRY
CLAIMS ACTIVITY REPORT
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PROVIDER SEARCH FUNCTION
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COFINITY BILLING RULES
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GET CURRENT PRODUCT PAYER LISTS
UPDATED QUARTERLY
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You can also escalate to Cofinity on the website:
• Go to Cofinity.net / click on a link at the bottom of the page that says “Contact Us”
• Select Customer Service option
• There is a dedicated team of people that work that mailbox on a daily basis.
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CONTACT INFORMATIONwww.AETNA.com
Aetna Credentialing Aetna Provider Service
1-800-353-1232 1-888-632-3862
https://navinet.navimedix.com
Navinet Customer Service
1-888-482-8057
www.COFINITY.net
Cofinity Customer Service
1-800-831-1166
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Aetna Better Health
Secure Provider Web Portal:
www.aetnabetterhealth.com/michigan
Aetna Better Health Provider Relations:
1-866-314-3784
fax: 1-866-602-1251
Email: [email protected]
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THANK YOU!
QUESTIONS?