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.
Previously, UHC would not reimburse for COVID-19 testing when done outside of a skilled inpatient stay at a SNF.
However, during the PHE, starting Jan 27,2020 and then renewed on April 21,2021, subject to further extension, UHC is going to pay for the COVID-19 testing that is done outside of the skilled inpatient stay at a SNF.
This change applies to the following Medicare Advantage Plans:
Medicare Advantage Plans
Dual Eligible Special Needs Plans (DSNP)
Chronic Special Needs Plans (CSNP)
UnitedHealthcare Assisted Living Plans (IE-SNP)
FIDE/MMP Plans
Plans that this change DOES NOT APPLY TO:
UnitedHealthcare Nursing Home Plans (ISNP)
UnitedHealthcare commercial plans
UnitedHealthcare Community Plans (Medicaid Only Plans)
UHC will re-process theclaims, there is no further action needed.
UHC will reprocess claims previously paid at $0 to be reimbursed at 100% of the Medicare fee schedule. No action is required from affected SNFs for these adjustments.
The following codes are going be reimbursed at 100% of Medicare Fee Schedule:
Reminder!
COVID-19 testing performed during an approved skilled stay are subject to Centers for Medicare and Medicaid Services (CMS) consolidated billing rules and are not separately reimbursable, except for the UnitedHealthcare Nursing Home Plan (ISNP). New applicable CMS covered COVID-19 testing codes may be added periodically. We may add or remove codes from the following list, in accordance with CMS coverage guidelines.
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Group Retiree Medicare Advantage has two plans PPO and National Access Plus. These plans are offered through Anthem BCBS (Anthem).
Below please find the FAQs regarding these 2 plans:
What does Anthem BCBS Nevada Group Retiree Medicare Advantage PPO and National Access Plus Plans may include?
Group Retiree Medicare Advantage memberships may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan.
Extra services that traditional Medicare does not cover?
The PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online* and SilverSneakers®.*
Anthem Medicare Preferred (PPO):
Front of the card
Front of the card
Sample Mediblue Freedom (PPO) Plan cards:
Front of the card
Front of the card
What are the alpha prefixes for Group Retiree Medicare Advantage PPO members?
Do I need to participate in the Medicare Advantage PPO network to see members with the National Access Plus benefit? No contract is required. You can still see your current patients and new patients who have one of the following Medicare Advantage PPO plans: Anthem Medicare Preferred (PPO) Empire MediBlue Freedom (PPO)
What is the payment rate for out-of-network providers who treat Medicare Advantage PPO members with the National Access Plus benefit? Out-of-network providers are paid Medicare allowable rates for covered services, less the member’s copay, coinsurance, and/or deductible.
Does the member have a higher copay if they see me as an out-of-network provider?The National Access Plus benefit allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare. The member’s copay or coinsurance percentage will be the same whether his/her provider is in- or out-of-network. Whether local or nationwide, doctor or hospital, in- or out-of-network — the member’s cost share doesn’t change. If the member is in one of our PPO plans but the plan does not include the National Access Plus benefit, the member could have a higher copay. Please check member eligibility and benefits to verify the cost share.
How does a provider file claims for Medicare Advantage PPO members with or without the National Access Plus benefit? Providers may submit claims electronically using the electronic payer ID for the Anthem plan in their state or submit a UB-04 or CMS-1500 form to the Anthem plan in their state. Claims should not be filed with original Medicare. You can file a claim:
Online at availity.com.
Via mail by sending it to the medical claims and inquiries filing address on the back of the member’s ID card.
I do not participate in the Medicare Advantage PPO network. I am waiting to hear if a PA request is approved. Should I ask the member to reschedule or postpone the appointment until I have confirmation that my PA request is approved? Non-contracted providers are not required to request PA, but we recommend that you do so to ensure we can assist you with any questions or issues. Anthem will work with providers to approve PAs so members do not postpone appointments.
Are referrals required? No, members are not required to obtain a referral before they see a provider.
For a complete list of FAQs, including Utilization Management/Prior Authorization process information, please click here for a pdf attachment.
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