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


OLD ADDRESS IS NO LONGER VIABLE:

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

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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:


G0402-
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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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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