Posted in #aetna, #Medicare, #Medicareadvantage, Training, Updates

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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Posted in #aetna, #Medicare, #Medicareadvantage, Training, Updates

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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Posted in Training, Updates, #unitedhealthcare

UHC Commercial Plan: new prenatal ultrasound policy -2022

As of 06/01/2022- UHC announced a new prenatal ultrasound policy for the year 2022. The reimbursement for this policy will be determined post-service, with pre-pay based on the following:

  1. The first 3 prenatal ultrasounds are going to be covered and medical necessary: CPT® codes 76801, 76802, 76805, 76810, 76811, 76812, 76815, 76816 and 76817
  2. 4 or more ultrasounds will be considered proven and medically necessary for high-risk pregnancies, as described in the policy, when the treating provider will make therapeutic determinations based upon the results.

This policy applies towards professional services billed on HCFA1500 form and performed in POS 11 and 22.


This policy doesn’t apply to:

  • Prenatal ultrasounds rendered in an emergency room
  • Outpatient observation care
  • Inpatient hospital setting

Charging patients for NON-COVERED services:

Please note, you’ll need to get written consent prior to the service if you bill patients for services denied for lack of medical necessity. Patient consent will need an estimate of the charges and a statement of the reason you believe the service may not be covered. See the “Charging members for non-covered services” protocol in the UnitedHealthcare care provider administrative guide.”


Please click here to review the new  obstetrical ultrasound medical policy


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