AETNA BETTER HEALTH ® OF NEBRASKA 2015 AAHAM CONFERENCE.

AETNA BETTER HEALTH® OF NEBRASKA2015 AAHAM CONFERENCE

Aetna Inc.AETNA BETTER HEALTH

Welcome and Introductions

Provider Relations• Jeff Nelson- Provider Relations

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Our Core ValuesBe passionate about the people we serve Set high

expectations, be decisive and execute

Listen to customers, prioritize and deliver value

Trust and respect each other

Be open to all voices and ideas

Be collaborative, caring and optimistic

Be courageous, try new things and innovate

Coach, mentor and continuously learn

Anticipate the future and make a difference

Communicate with candor

Behave ethically and act with integrity

Be accountable and honor commitments

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Our Members – The Center of What We Do

MemberOperations & Enrollment

Member Services & Member

Advocates

Quality Management

Provider Relations &

Provider Network Appeals &

Grievances

Medical Management

Collaborative Services

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Provider Relations• Aetna Better Health of Nebraska has dedicated Provider Relations staff • Provider Relations staff will visit provider offices regularly throughout the

year to ensure Aetna is meeting their needs and addressing concerns • Provider Relations will:

─ Provide education to provider offices on a variety of topics─ Provide support on Medicaid policies and procedures─ Provide contract clarification─ Assist with demographic changes, terminations, and initiation of

credentialing ─ Monitor compliance with applicable State and Federal agencies─ Conduct annual Provider Satisfaction Survey ─ Conduct member complaint investigation─ Maintain the provider directory─ Be a point of contact for provider concerns

Provider Relations can be reached at (888) 784-2693

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Claims Inquiry/Claims Research (CICR)

• Claims Inquiry/Claims Research (CICR) will: ─ Be the first point of contact for providers with any claims questions─ Assist with claims questions, inquiries and reconsiderations─ Review claims or remittance advice

Claims Inquiry/Claims Research can be reached at (888) 784-2693

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Member Services

• Member Services will:─ Provide information on eligibility and benefits ─ Assist providers with non-compliant members and/or discharges─ Assist members with available programs and resources─ Assist member in finding providers─ Assist members in filing grievances or appeals

Member Services can be reached at (888) 784-2693

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Member ID Cards

• New ID cards were issued on 8/25/14. All CoventryCares members should have new Aetna Better Health of Nebraska ID cards.─ If the member does not have his/her new ID card, you can obtain enrollment

verification at http://aetnabetterhealth-nebraska.aetna.com . • Aetna Better Health will use the existing Medicaid ID number issued by the

State of Nebraska

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http://aetnabetterhealth-nebraska.aetna.com/


Member Eligibility

• Aetna Better Health of Nebraska member eligibility can be verified through ─ Provider portal (http://aetnabetterhealth-nebraska.aetna.com), or─ Member Services (888) 784-2693─ NMES Line (402) 471-9580 or (800) 642-6092

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Prior Authorization

• Please review the new authorization requirements that went into effect August 25, 2014

• Request new prior authorizations─ Online: CareWebQI , access through the provider portal─ Phone: (888) 784-2693─ Fax: (844) 213-9659

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Claims Submission

• NEW Aetna Better Health of Nebraska EDI payer ID: 42130• NEW claims mailing address:

Aetna Better Health of NebraskaP.O. Box 63188Phoenix, AZ 85082-3188

• All claims should be submitted on the most current claim forms

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Claim Timely Filing

• Timely filing for Aetna Better Health of Nebraska for initial claims submission follows your Coventry Health Care of Nebraska HMO contract

• Providers will have 180 days from the date of an initial claim denial to submit corrected claims or requested information

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Provider Website

• http://aetnabetterhealth.com/Nebraska • Our provider website contains resources to assist provider interactions

with Aetna Better Health of Nebraska:─ View and download our provider manual, communications and

newsletters─ Searchable provider directory─ Reconsideration and appeal forms─ Clinical practice guidelines─ Member materials─ Fraud & abuse information and reporting ─ Gateway to our secure provider web portal─ Information on resubmission and provider appeals─ Review the member and provider handbooks

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Provider Portal

• Please visit: http://aetnabetterhealth-nebraska.aetna.com• Providers will be able to

─ Search member eligibility and verify enrollment─ Search and initiate authorizations (CareWebQI)─ Search claims status─ View claim detail, explanation of benefits and remittance advice─ View provider lists and panel roster─ Contact the health plan via secure messaging

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Provider Portal

• http://aetnabetterhealth-nebraska.aetna.com • All providers must register for the provider web portal prior

─ Submit web portal e-registration forms online─ See our provider web portal navigation guide to learn more about the

provider web portal available on the provider website• Each TIN will have one account, with a primary representative

─ The primary representative can add authorized representatives within their office to their account

• Contact Provider Relations for help registering

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Electronic Tools

• Electronic claims submission─ Payor ID 42130─ Less paperwork, less wasted time, and a more efficient office─ Lower claims rejection rates ─ Faster claim delivery than by traditional mail – clean claims mean less

money wasted for reprocessing─ Faster claim payment to your office─ Ability to easily identify and resubmit claims with missing or invalid data

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Electronic Tools• Electronic funds transfer (EFT) - Electronic funds transfer (EFT) will be our standard payment method for provider reimbursement as of August 1, 2014• Electronic remittance advice (ERA - 835 files) - RAs will no longer be mailed to your office effective August 1, 2014, or 30 days after you sign up for EFT • Please work with your clearinghouse to ensure you can receive ERA &

have the correct file paths• Enroll in EFT/ERA electronically by visiting our Secure Web Portal

http://aetnabetterhealth-nebraska.aetna.com • Paper forms can be found on the provider website

Sign up for EFT/ERAPlease contact Provider Relations at (888) 784-2693 or

e-mail [email protected] with questions or to check EFT enrollment status.

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mailto:[email protected]


Claim Resubmissions & Reconsiderations

• Resubmission claims may be sent electronically • Label all corrected claims as “Corrected Claim” on the claim form

─ Send all claim lines again, not just the line being corrected• Send paper reconsideration claims with attached documentation to:

Aetna Better Health of NebraskaAttn: Claims Resubmission/ReconsiderationP.O. Box 63188Phoenix, AZ 85082-3188

• Please use the Reconsideration Form found on the provider website http://aetnabetterhealth.com/Nebraska

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http://aetnabetterhealth.com/Nebraska


Appeals• Our provider appeals process is utilized to dispute an adverse action

of a denial, reduction or termination of a requested service─ Post-service appeals are initiated in writing by mail─ The appeal must specifically state the factual and legal basis for the

appeal and the relief requested─ Documents to support the appeal should be provided, such as a

copy of the claim, remittance advice, medical review sheet, medical records, correspondence, etc.

─ Appeals on issues other than claims denials, such as authorization denials, must be filed no later than 90 days after the date of the adverse action

• Appeals are reviewed within 90 days─ Once you receive a notice of resolution, this will conclude your

appeal process

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Grievances

• A grievance is any written or verbal expression of dissatisfaction over a matter other than an action by a member or provider authorized in writing to act on the member's behalf.

• Examples: Quality of care, quality of service, provider behavior, office environment, potential fraud and abuse

• Grievance process─ Acknowledged within 5 calendar days─ Investigated by provider relations, quality management and/or by the State’s

Ombudsman─ May involve office site visits and assessments─ Egregious grievances may warrant peer review and/or trigger an off-cycle

credentialing review─ Resolution and response to the member within 90 calendar days

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Quality Programs

• EPSDT ─ Monthly post card mailing & reminder calls

• Well Woman ─ Monthly birthday card mailing

• Case Management─ Pediatric, adult, perinatal

• Disease Management─ Diabetes, congestive heart failure, asthma, COPD

• Member Advocates• Prevention and Wellness• Patient Centered Medical Homes • Readmission Prevention• ED utilization, inpatient admission & readmission reports• HEDIS

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Provider Credentialing

• The Aetna Better Health of Nebraska credentialing process will be monitored by a Aetna Better Health of Nebraska dedicated Credentialing Coordinator

• Contact your Provider Relations representative to initiate credentialing of a new provider─ Please remember to contact the Coventry Commercial plan─ Aetna utilizes the CAQH online, universal application

• Aetna Better Health of Nebraska will not be able to assign retroactive effective dates for new providers

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Provider Manual

• The provider manual is a resource for policies and procedures for Aetna Better Health of Nebraska─ Access it online at: http://aetnabetterhealth.com/Nebraska

• Please review this manual for additional information about Aetna Better Health of Nebraska including:─ Contacts─ Provider rights and responsibilities─ Credentialing─ Member eligibility and enrollment─ Billing and claims─ Reconsiderations, appeals and grievances

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Aetna Inc.AETNA BETTER HEALTH 24

NDC Validation

• The State of Nebraska determines which codes are required to be billed with NDC information.

• If a CPT/HCPCS code which requires an NDC is billed, but no NDC information is present, the claim line will be denied.

• NDC information submitted on a claim is validated against a standard NDC dataset (MediSpan is the source of this dataset) to validate that the NDC number, unit of measure, and quantity is valid.

• Deactivated or terminated NDCs cannot be accepted. • The approved unit of measure (F2, GR, ML, UN, or ME) must

be billed.


NDC Validation (Continued)

If a NDC is submitted when not required by the State of Nebraska for drug rebate submission, it will still be validated for accuracy.


NDC Continued

Effective December 22, 2014, Aetna Better Health will begin reviewing NDC dosage information. When an NDC is required, a dosage is required to be sent with the NDC information. If the dosage is over or under the standard dosage limits, medical records will be required to process the claim. If records are not sent, the claim line will be denied. If a claim is denied, please resubmit the claim with medical records and a reconsideration form


EPSDT Modifier and Referral Indicator Codes

• For Early and Periodic Screening, Diagnostic, and Treatment (EPSDT or Health Check) services, it is essential to bill these codes with an EP modifier. EPSDT services not billed with the EP modifier will result in a claim line denial.

• In addition, one of the following referral indicator codes must be included on claims using CPT well-child preventive codes 99381-99395 with the required EP modifier. (Electronic 837P or CMS 1500 box 24H).


EPSDT Modifier and Referral Indicator Codes (Continued)

AV - Patient refused referral S2 - Patient is currently under treatment for diagnostic or corrective health problem NU - No referral given ST - Referral to another provider for diagnostic or corrective treatment


VFC (Vaccines for Children)

VFCVFCs are not required to be billed with NDC information. The following codes are excluded from NDC validation: 90471, 90472, 90473, 90474, 90633, 90649, 90658, 90707, 90710, 90716, 90734, 90664, 90666, 90667, 90668, 90648, 90669, 90681, 90713, 90721, 90748, 90650, 90718, 90685, 90660, 90686, 90655, 90656, 90657, 90670, 90714, 90715, 90744, 90746, 90647, 90672, 90680, 90696, 90698, 90700, 90723

Additional information for UB BillingNDC information is required for specific revenue codes (0250, 0251, 0252, 0254, 0631, 0632, 0634, 0636, 0637) and bill type combinations (130-149, 710-749, or 830-839).


Web Portal Demo

Aetna Better Health of Nebraska is hosting webinar sessions to assist providers with functions of the secure provider web portal:

Any provider who wishes to participate will need to register. Please email us with your name, email address, date & time preferred. All registered providers will receive an email invitation to the webinar with further instructions the day prior to the scheduled webinar. Please check provider news for dates and times.

mailto:[email protected]


Thank you

Please sign up to receive Aetna Better Health of Nebraska news and updates at http://tinyurl.com/mnnu5cn.

http://tinyurl.com/mnnu5cn

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