Posted in #aetna, #Medicare, #Medicareadvantage, Training, Updates

Aetna: Mid level practitioner reimbursement policy-07/01/2022

This reimbursement policy update applies to AETNA Commercial Plans for Texas Medicare, Commercial and IVL exchange networks.


Recently, AETNA expanded their policy for midlevel reimbursement policy- that includes reimbursement at 75% of the negotiated fee or recognized charge for
covered services for the following mid level professionals:

audiologists, genetic counselors, massage therapists, nutritionists, respiratory therapists and registered dietitians


Effective 07/01/2022- AETNA will add reimbursement of 85% of physician market rate, unless otherwise contracted for (nurse practitioners, certified nurse midwives, physician assistants and clinical nurse specialists) regardless of contract, employment status or place of service (that is, office or facility).


Who and what is not affected?
• Mid-level providers with specific rates in their contract
• Certified registered nurse anesthetists and registered nurse first assistants
• Claims billed with an Assistant Surgery modifier
• Covered DME, orthotics, prosthetics, supplies, drugs, laboratory, radiology services
and immunizations billed by a mid-level practitioner
• Providers contracted through a third party or vendor


Does this change affect the precertification and concurrent management process?

No. Aetna® will continue to make utilization management decisions and send the
appropriate letters and other communications.


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Aetna Medicare Advantage: Home Health Program in KY, OH, MO

Since 08/01/2021 Aetna has partnered with myNEXUS, a technology-enabled care management company, to manage the network, claims payment and precertification/prior authorization program for home health services.


Note the following changes for the Providers:

Prior approval changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will require advance approval for all home-health-related requests for in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide, and medical social work.
  2. If you would like to view the full home health care pre-auth list, please click here (insert link)

Claim Payment and Processing changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will pay claims for covered home health services, for Kentucky, Ohio and Missouri Medicare Advantage members
  2. Reimbursement rates will correspond to the rates and terms of your myNEXUS contract.

Important!

1.These above changes apply only to the Aetna Medicare Advantage Members that reside in the three states, and/or Aetna Medicare Advantage DSNP members, in the above mentioned 3 states.

2. These changes DO NOT APPLY TO THE FOLLOWING:

Medicare members residing outside of the states of Kentucky, Ohio and/or Missouri

Aetna and Coventry commercial fully insured HMO/POS/PPO plans • Aetna administrative services only (ASO) self-funded HMO/POS/PPO plans

Aetna Student Health℠

Aetna Global Business • Coventry Workers’ Compensation  

Cofinity®

First Health®, Meritain® Health, Traditional Choice®

Aetna Signature Administrators® 


Where do I order a prior approval?

  1. Online: myNEXUS portal to get started or

2. Fax the authorization request form to 1-866-996-0077


Find this type of content helpful? Follow my blog for more payer network news, medical billing and coding updates, reimbursement/medical policy changes.

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Posted in #aetna, #Medicareadvantage, Training, Updates

Aetna Medicare Advantage: Home Health Program in KY, OH, MO

Since 08/01/2021 Aetna has partnered with myNEXUS, a technology-enabled care management company, to manage the network, claims payment and precertification/prior authorization program for home health services.


Note the following changes for the Providers:

Prior approval changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will require advance approval for all home-health-related requests for in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide, and medical social work.
  2. If you would like to view the full home health care pre-auth list, please click here (insert link)

Claim Payment and Processing changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will pay claims for covered home health services, for Kentucky, Ohio and Missouri Medicare Advantage members
  2. Reimbursement rates will correspond to the rates and terms of your myNEXUS contract.

Important!

1.These above changes apply only to the Aetna Medicare Advantage Members that reside in the three states, and/or Aetna Medicare Advantage DSNP members, in the above mentioned 3 states.

2. These changes DO NOT APPLY TO THE FOLLOWING:

Medicare members residing outside of the states of Kentucky, Ohio and/or Missouri

Aetna and Coventry commercial fully insured HMO/POS/PPO plans • Aetna administrative services only (ASO) self-funded HMO/POS/PPO plans

Aetna Student Health℠

Aetna Global Business • Coventry Workers’ Compensation  

Cofinity®

First Health®, Meritain® Health, Traditional Choice®

Aetna Signature Administrators® 


Where do I order a prior approval?

  1. Online: myNEXUS portal to get started or

2. Fax the authorization request form to 1-866-996-0077


Find this type of content helpful? Follow my blog for more payer network news, medical billing and coding updates, reimbursement/medical policy changes.

Recent Blog Posts: