Posted in #aetna, #Medicare, #Medicareadvantage, Payers and CPT reinbursement

Aetna Commercial and Medicare Plans: Payment for Occupational Therapy/Physical Therapy Assistants

As per Aetna Updates: starting December 1,2023 the Occupational Therapy Assistants and Physical Therapy Assistants will get their own reimbursement for performed services.

Reimbursement amount: 85% of Allowed amount.

Please append the following modifiers to the services that are performed by the PTAs and OTAs:

CO-occupational therapy services performed in part or as a whole by an Occupational Therapy Assistant

CQ-physical therapy services performed in part or as a whole by a Physical Therapy Assistant.

This change applies to Medicare and Commercial plan types.

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NYS Medicaid POC Syphilis testing coverage

Effective for any DOS August 2025 and thereafter Point of Care testing for Syphilis is covered for all fee fo service Medicaid and Managed Medicaid Members. Where is this test covered (POS)? physician/nurse practitioner/licensed midwife private office setting What kind of POC is covered and reimbursed? Currently there is only one FDA approved test -Clinical…

NYS Medicaid OBGYN CPT II codes reporting requirement

If you are a provider in NY and accept Managed Medicaid or Fee-for-service Medicaid plan types, then this blog post post is for you! For any DOS (for deliveries on July 1, 2024) and thereafter, the OBGYN providers billing bundled/global OBGYN codes, are also required to bill the following CPT II reporting codes. Global OBGYN…

NYS Medicaid: Bariatric Surgery Medical Policy Update

Do you accept NYS Medicaid or Managed Medicaid Plan members? Then this blog post is for you! Non surgical treatment should be attempted: ex. diet and increased exercise. Bariatric Surgery Adult Patient: 18 years old and over Pediatric patients: 18 years and older – patients that are deemed physically, mentally, and emotionally mature by a…

Posted in #aetna, Training, Updates

Aetna Better Health of Florida to pay for certain Z codes

Do you or your office reports social determinants and accept Aetna Better Health members? Great news! Now according to an update sent to the physicians, the insurance plan will reimburse for certain Z codes that correspond to certain social determinants of health.


Some of these Social Determinants of Health include (not all included):

• Assistance reapplying for Medicaid benefits
• Transportation: ModivCare
• Cleaning: Pest control, carpet cleaning, house cleaning
• Housing Specialist: assist with housing searches, voucher applications, transitioning from institution to
community
• Member Advocates: assist with coordinating and access to community resources
• In-office care management support for provider or specialist visits
• Peer support specialist
• Disease management education
• Smoking cessation support services

The Z codes will be reimbursed when they are billed with code: G9919

Partial list of covered Z codes:

For full list of the covered Z codes that are covered, please click here.


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NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding

Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you! When: this applies for any services done on/and after Jan 1, 2026. Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient…

Hedis Measure: Controlling Blood Pressure Controlling Blood Pressure

Are you a provider that participates in reporting HEDIS measures? Then this blog post is for you! What is this measure: the measure assesses if adults (18-85) with hypertension have their blood pressure adequately controlled, below 140/90 mm Hg. and below 130/80 Hg. Documentation Requirements: 1. Adults 18-85 with a hypertension diagnosis.  2. At least…

North Carolina Medicaid- self collected HPV test info.

In March of 2024- FDA apprpved a self collecting HPV test. It is a self collected HPV testing in a healthcare setting- patient uses a swab or brush in a private room (like in a doctor’s office) to collect their own vaginal sample for cervical cancer screening. As of May 1st 2025, NC Medicaid added…

pre

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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