Posted in Insurance, My services, Training, Updates

Aetna Better Health of Louisiana (ABHLA)-Specialized Behavioral Health Claims-Reimbursement update

This policy applies to services performed in a facility: HCPCS and CPT codes

Aetna Better Health of Louisiana would like to remind providers that its Behavioral Health Reimbursement policy is aligned with the Louisiana Department of Health’s Medicaid Services. Providers need to check the Provider Manual regarding the proper billing practices for Behavioral Health Services. If the manual requires additional guidance for appropriate reimbursement, the details will be outlined by ABHLA in a supporting reimbursement policy.

To check the compliance with billing practices of the Louisiana Department of Health’s Medicaid Services, Aetna Better Health of Louisiana conducted an internal audit. ABHL found that many of the claims did not have the INDIVIDUAL PROVIDER as RENDERING provider but instead a FACILITY was listed as a rendering provider.

In order to comply with the proper billing and coding for these services, done in a facility setting, please put an INDIVIDUAL RENDERING PROVIDER NPI in the box 24J on the HCFA 1500.

Below are just some codes that might have been paid previously (with a facility NPI):

Claims with the Facility NPI listed as the rendering provider will be denied and paid claims may
be recovered by the health plan. Should you receive denials for this reason, you may rebill your
denied claim(s) as a corrected claim with the Individual Provider NPI listed as rendering for
ABHLA to reprocess and pay the claim(s).

Please note that providers may see reimbursement impacted if not aligned to the Louisiana
Department of Health’s Medicaid services manual within 30 days of the date of this notification.

Below is just a partial list of the Louisiana Department of Health’s Medicaid Services: Behavioral Health Services Fee Schedule:

For a full list of the Fee Schedule, please click here

Posted in Insurance, My services, Training, Updates

UHC Community Health (NY) Specialist Referral Requirements, 03/01/2021

These Specialist Referral Requirements will apply to the following:

  • UnitedHealthcare Community Plan for Families (Medicaid)
  • UnitedHealthcare Community Plan Wellness 4 Me (HARP) 
  • UnitedHealthcare Community Plan ChildHealthPlus (CHP)

This new change will take effect on 03/01/2021. The referrals will need to be generated by the member’s PCP. Primary Care Providers can begin to request a referral for any date on 03/01/2021 and thereafter.

Between now and 03/01/2021, in network specialists will continue to get reimbursed as usual.

The following services that WILL NOT REQUIRE A REFERRAL:

  • Women´s Health Care
  • Family Planning 
  • HIV and STI Screening
  • Eye Care (subject to benefit limits in member handbook)
  • Dental Care
  • Behavioral Health – (Mental Health and Substance Use)
  • Smoking Cessation
  • Maternal Depression Screening
  • Services rendered in any emergency room or network urgent care center
  • Physician services for emergency/unscheduled admissions
  • Any services from inpatient consulting physicians
  • Radiologist, Pathologist, Anesthesia, etc. Providers that are part of inpatient hospital care or surgical teams do not need referrals
  • A specialist who has arranged to act as the member’s PCP does not need a referral for him or herself. Please see FAQs for additional information. Any other services for which applicable laws and regulations do not allow us to impose a referral requirement.

ANY services that are NOT LISTED above will REQUIRE a REFERRAL from the PCP to the IN-Network Specialist.

If you have any questions, please call: 888-362-3368. 

#UHC #referral #specialists #PCP #NYproviders #communityhealth #HARP #nymedicaid

Posted in Insurance, My services, Training, Updates

Aetna: New Medicare Advantage Plans in North Carolina, South Carolina and Tennessee- 01/01/2021

As of 01/01/2021- there are 2 new HMO plans that will be available in NC, SC and Tennessee: These plans are Aetna Medicare ValueSM Plan (HMO) and Aetna Medicare Value Plus Plan (HMO)

These plans will require to choose a PCP. However, they will NOT require a referral to see a specialist. This information will be on the member cards, as indicated by the red arrow below:

The following is the list of the plan types:

Supplemental Benefits: NOT all plans will have these available

  • Dental (preventive and comprehensive)
  • Over-the-counter (OTC)
  • Hearing Aids
  • Post hospital discharge meal delivery
  • Telehealth

Additional Information:

  • All members must select a primary care physician.
  • There is no referral requirement for specialty care.
  • Participating providers can submit pre-authorization requests through our provider portal, or they can also fax the request or call it in to the Provider Service Center.
  • These plans include pharmacy Part D coverage.

Note: No out-of-network benefits exist for these plans unless the member follows the approval process. They can start this process by contacting Member Services directly.