Tag: #physicaltherapy

Posted in #aetna, #Medicareadvantage, Training, Updates

Aetna Medicare Advantage: Home Health Program in KY, OH, MO

Posted on by KR2Medical Billing

Since 08/01/2021 Aetna has partnered with myNEXUS, a technology-enabled care management company, to manage the network, claims payment and precertification/prior authorization program for home health services.

Note the following changes for the Providers:

Prior approval changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will require advance approval for all home-health-related requests for in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide, and medical social work.
  2. If you would like to view the full home health care pre-auth list, please click here (insert link)

Claim Payment and Processing changes:

  1. Effective for DOS 01/01/2022 and thereafter, myNEXUS will pay claims for covered home health services, for Kentucky, Ohio and Missouri Medicare Advantage members
  2. Reimbursement rates will correspond to the rates and terms of your myNEXUS contract.

Important!

1.These above changes apply only to the Aetna Medicare Advantage Members that reside in the three states, and/or Aetna Medicare Advantage DSNP members, in the above mentioned 3 states.

2. These changes DO NOT APPLY TO THE FOLLOWING:

Medicare members residing outside of the states of Kentucky, Ohio and/or Missouri

Aetna and Coventry commercial fully insured HMO/POS/PPO plans • Aetna administrative services only (ASO) self-funded HMO/POS/PPO plans

Aetna Student Health℠

Aetna Global Business • Coventry Workers’ Compensation  

Cofinity®

First Health®, Meritain® Health, Traditional Choice®

Aetna Signature Administrators® 

Where do I order a prior approval?

  1. Online: myNEXUS portal to get started or

2. Fax the authorization request form to 1-866-996-0077

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Posted in Oscar Insurance, Training, Updates

Oscar Insurance: New Physical and Occupational Therapy Prior Authorization Process

Posted on by KR2Medical Billing

I am getting a lot of request from PT/OT providers, regarding the new Oscar Insurance “medical necessity” review process. So, I decided to write a FAQ blog post on this subject.

Are you a PT or OT provider? Do you accept patients with Oscar Insurance? Then this blog post is for you!

What you will learn in this blog post?

1. Know who to contact to get your authorization on the first submission.

2. Avoid unnecessary denials!

3. Keep yourself and your staff current on the most updated medical billing/authorizations guidelines.

Let’s begin.

Recently Oscar Insurance announced that effective 07/15/2021, the “medical necessity for Physical and Occupational Therapy”, will be handled by the American Specialty Health Group, Inc. (ASH Group).

For the purposes of this blog “medical necessity” is interchangeable with “prior authorization”

Below are the most frequently asked questions and their answers:

  1. I am a participating OT/PT provider; how do I submit an authorization?

As a participating provider, you have several ways to submit medical notes for prior auth.

  1. Provider portal: www.ASHLink.com
  2. Fax: 877-248-2746
  3. Mail: American Specialty Health (ASH) PO Box 509077, San Diego, CA 92150-9077

2. Where can I find information regarding clinical documentation?

The clinical information guidelines are available on the website : www.ASHLink.com . On the website you need to click Resources then Providers then Physical , Occupational and Athletic Training and then click on Practitioner Claims Packet-Oscar.

3. Do I need to register with ASH in order to view the necessary information?

Yes, in order to access any information regarding the prior authorization criteria and documentation requirements, you have to register with ASH and/or activate your account.

4. I am a participating Provider (with Oscar), where should I go to verify patient’s eligibility?

A participating provider should go to hioscar.com/provider or call 1855-oscar-55 to verify the member eligibility, before requesting a PT/OT medical necessity review.

5. Will my claim will be denied if I do not obtain a prior authorization (PT/OT) before sending the claim for processing?

Yes, it will be. As a participating provider it is the responsibility to obtain a “medical necessity review” prior to submitting claims for payment.

6. Where do I submit PT/OT claims to?

As a participating PT/OT provider you will submit the claims directly to Oscar at:

Oscar Insurance Corporation

PO Box 52146

Phoenix, AZ 85072-2146

7. How do I file an appeal?

If the PT/OT services are denied, as a participating provider you have the right to file an appeal. That information is going to be included in the determination documentation.

8. If I am a participating provider who can I contact for more information?

Please contact Oscar Provider Services at 1-855-OSCAR-55

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Do yo need more hands on help: training or consulting? Please contact me via email:

Consulting: kr2medialbilling@gmail.com or for educational/training at cskr2billing@gmail.com

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Posted in Insurance, Training, Updates

EmblemHealth (NY) Physical Therapy/Occupational Therapy Program Reminder

Posted on by KR2Medical Billing

This is a reminder for PT/OT providers that see EmblemHealth HIP (Health Insurance Plan of Greater NY), and HIPIC (Insurance Company of NY), and GHI EPO/PPO non-City of New York patients (added to the list)

EmblemHealth partnered with Palladian Muscular Skeletal Health- a specialty network and utilization management company.

Q1.  What is Palladian is responsible for?

A1. Palladian is responsible for the following functions:

a. Administration of Prior Authorizations PT/OT services in outpatient setting  (private physician Office)

b. Administration of Prior Authorizations PT/OT services done in hospital outpatient facility setting, only for eligible members.

c. Payment for PT/OT professional claims

d. Appeals for denied claim determinations – professional claims

e. CREDENTIALING And RE-CREDENTIALING of network PT/OT providers.

Q2. What plan is excluded?

A2. Medicare Plans

Q3. What is EmblemHealth is responsible for?

A3. EmblemHealth is responsible for payment and appeals for denied determinations of PT/OT services that are performed in the hospital outpatient facility setting.

Q4. How to submit PT/OT request?

A4. Please visit  Palladian website: http://www.palladianhealth.com or by phone: 877-774-7693 or by fax: 716-809-8324