Posted in #Medicare, #Medicareadvantage, BCBS (Various States), Training, Updates

BCBS California: Authorizations for post-acute care services (Medicare Advantage Plans/GRS)

The following blog will discuss where and how the providers should submit their prior authorizations for post-acute care services for Medicare Advantage Individual, Group Retiree Solutions, and Dual Eligible Plan members.

Note: Dual Eligible- member qualifies for Medicaid and Madicare.

This change is applied for services rendered on Sept 1, 2022 and thereafter. The services included are: admission to or concurrent* stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH).

These services will be reviewed by myNEXUS.**

*Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to September 1, 2022, should be directed to the health plan.

** myNEXUS is an independent company providing post-acute benefits management services on behalf of Anthem Blue Cross.

How to submit or check a prior authorization request

For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests on Tuesday, August 30, 2022, for members whose anticipated discharge date is September 1, 2022, or after.

Providers can send their request online- Go to to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day.

If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 1-833-311-2986.

Note: myNexus does not review requests for DME, Ambulance- These services do not fall under the Medicare Home-health services: infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under Essential/Everyday Extras.

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

Aetna Medicare Advantage: participating providers’ post-service appeals new address

Are you an Aetna Medicare Advantage participating provider and had issues with your post-service appeals? If your answer is yes, it is because as of Jan 1, 2022 there is a new address where the providers need to submit those appeals to.

There is also a NEW FORM that the provider needs to fill out.

Where to find the new form?

You can find this form, which is called the Medicare Provider Complaint and Appeal Request Form, by going to the forms for health care professionals page and scrolling to the “Dispute and appeals” drop-down menu.

The New form should be sent to the address below:

Medicare Provider Appeals PO Box 14835 Lexington, KY 40512 Fax: 1-860-900-7995


Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax: 1-800-624-0756

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

Aetna and Mid Level Reimbursement EM Services update 2022

According to Aetna June 2022 provider newsletter- Aetna will NO Longer pay for the mid level staff: nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists, at 100%, if they are performing the following codes:

Long description:
Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment
Short description: Initial preventive exam

G0438- Long description: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Short description: Ppps, initial visit

G0439- Long description: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Short description: Ppps, subseq visit

Note to Washington State providers: Your effective date for changes described in this article will be communicated following regulatory review.

How can you access the full policy?

Log in to Availity*** and follow these steps:

  1. Click on Payer Spaces > Aetna.
  2. In the search box, type “mid-level practitioners” and click Search.
  3. Choose “Mid-level Practitioners and Other Qualified Health Care Professionals — Resource.”

This policy applies to Aetna commercial and Medicare members.

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