The Illinois Department of Healthcare and Family Services is planning to contract with two qualified managed care organizations for its Integrated Care Program. This program will provide adults with disabilities and older adults in the Medicaid program the full spectrum of Medicaid covered services. The Integrated Care Program is a pilot program that will serve this Medicaid population.

As health care reform continues to focus on significantly transforming the delivery of care to the most vulnerable populations covered by the Medicaid program, we believe that the opportunity to provide health care services for this population is the appropriate direction for you and for Aetna.

The State of Illinois believes that the Integrated Care Program will be an opportunity to design services that allow for community living and prevent unnecessary institutional care or shorten the time in institutions.

Since we cannot discern which MCO(s) the State will select, and to avoid disruption of the membership (who may currently be your patients), we encourage you to sign this contract now.

The State of Illinois is interested in ensuring that it has the most innovative and cost-effective managed care organizations working with them to provide plan administrative services to this Medicaid population.

Aetna Better Health is including providers who are currently participating with other Illinois Medicaid managed care organizations as well as providers that are interested in entering into the Medicaid managed care program.

Aetna Better Health will support you in the management of the member’s care, which may increase PCP visits, case and disease management programs, and help avoid unnecessary services and ER visits.

Aetna Better Health believes that the patient-centered medical home is the central model for effective and efficient delivery of comprehensive primary care to Enrollees in the Integrated Care Program. Medical homes have the potential to positively impact the health status of our Enrollees through: 1) designation of a personal primary care provider (PCP); 2) a whole-person orientation; 3) use of evidence-based medicine and health information technology; and 4) integration/coordination of care across an Enrollee’s conditions, providers and settings.

We expect the development of “well-resourced medical homes” to unfold as our collaboration with providers increases, given the developmental nature of the concept and execution of medical homes nationally. Our first step in establishing a network of medical homes will be to survey provider practices to determine those that have the key characteristics of a medical home/PCP. More information will be sent out to the network in the event that we receive the contract award from the state

Aetna is fully committed to serving the most vulnerable segments of the population. In fact, our mission is to do just that. We are excited about the opportunity to partner with the state and providers in Illinois to deliver a program that will meet the needs of adults with disabilities and older adults eligible for the Integrated Care Program.

Aetna Better Health is prepared to provide services to assist in better managing your Medicaid members. Specifically, we offer programs to help you work more effectively with the Medicaid populations — services including support to schedule your patients more effectively and profiling tools to help you to better identify and manage high risk members and have easier access to disease management and other programs.

Our infrastructure and commitment to this program are for the long run.

Our goal is to build the best network of providers.

Aetna Better Health is committed to working with providers on improving health outcomes of the Medicaid population. We have over 20 years of experience and proven capabilities with the aged, blind, hearing impaired and disabled population and expertise implementing Medicaid programs, which meet member and provider needs.

Our services will be tailored and customized to meet the needs of the state’s Medicaid Integrated Care Program and your needs as a participating provider in the Aetna Better Health network.

Aetna has extensive experience operating Medicaid plans throughout the country. Our teams and systems are operating in 12 states, serving nearly one million Medicaid beneficiaries.

The Aetna Better Health fee schedule is competitive with the market and reflective of Medicaid rates.

Yes, the State of Illinois DFHS has an established fee schedule. It can be accessed via this link:

http://www.hfs.illinois.gov/reimbursement/

Providers who contract with Aetna Better Health will receive a provider handbook outlining the claims submission policies and procedures. The provider handbook and other information will be available online and through a provider specific portal.

Providers will need to go to the Department of Health and Family Services website and register with the State of Illinois to become a Medicaid provider. The email address is:

http://www.dhs.state.il.us/page.aspx?item=27896

You can call the Aetna Better Health Provider Services department at 1-866-212-2851. This department is staffed from 8am to 5pm CST.

If you are currently an Aetna commercial provider, further credentialing is not necessary.

If you are not currently credentialed through Aetna, you must subscribe to CAQH and provide us with your CAQH number. We will perform the credentialing through the CAQH on line service. The CAQH website is listed below:

https://upd.caqh.org/oas/

Completing, signing and returning the Provider Application Form and the contract is the first step in becoming an Aetna Better Health network provider. The provider or person with signatory authority should sign and date the contract. The contract effective date will be completed by Aetna Better Health.

Be sure to complete each item in the contract, paying special attention to the contract checklist. For multiple providers in your practice, simply attach a separate sheet of paper with provider’s information, including specialty, Medicaid # and NPI, and include the individual provider addendum(s).

This information should be sent to:

Aetna Better Health
Attention: Provider Services
One South Wacker Dr F646 Ste 1200
Chicago, IL 60606

Once you have completed credentialing, the contract execution is completed by Aetna Better Health, the provider/office will receive a final copy of the contract, a contract effective date and a welcome package.

A: Enrollment is mandatory for people who are aged, blind, and/or disabled and living in the following counties: Lake, Kane, Dupage, Will, Kankakee and suburban Cook (not 606 zip code). The Illinois Department of Healthcare and Family Services (HFS), through the Illinois Client Enrollment Broker (ICEB), notifies members that they are eligible for this program and that they can choose Aetna Better Health as their health plan on a voluntary basis for the first 90 days. Members become effective the first day of the following month after they choose Aetna Better Health. HFS will auto-assign members (50/50 split) between Aetna Better Health and IlliniCare. Members will be auto assigned within the first 60 days if they do not voluntarily enroll.

Before rendering services, providers must always verify eligibility on the date of service. Providers have several available options to verify eligibility: Call 1-866-212-2851 (24/7) option 1. Through Aetna Better Health’s secure web portal.

Providers may also continue to use the existing Medicaid eligibility verification methods set up by the state of Illinois.
MEDI information is available at: http:// www.myhfs.illinois.gov/.
REV information is available at: http://www.hfs.illinois.gov/rev/.
The MEDI and the REV systems are available 24 hours a day, 7 days a week

Member transition is defined as: Aetna Better Health’s responsibility for transferring a member’s care into or out of Aetna Better Health or assisting in the member’s transition from one practitioner or provider to another.

The purpose of Aetna Better Health’s member transition is to provide a framework to guide Aetna Better Health staff in taking appropriate steps. The objective is to continue a member’s care continues without interruption or delay during their transition into or out of Aetna Better Health or between providers. Aetna Better Health maintains effective transition of care activities to monitor and provide a full continuum of care approach to providing health care services to Aetna Better Health members. This includes members who are currently under treatment for acute and chronic health conditions.

Aetna Better Health members can call the Member Services Department toll free at 866-212-2851. A member services representative will assist with the PCP change.

The change will be effective immediately upon the request of a new PCP.

It should be the provider’s goal to medically manage members so they comply with treatment plans and attend scheduled appointments, rather than to transfer non-compliant members to another provider. Providers may refer non-compliant members to our Case Management Department at 866-212-2851 to assist in promoting compliance by the member.

All medically necessary services, including prescribing needed medications until transition to new provider is complete. The transition of medical records and other necessary member information should be shared with the new provider as requested.

Medical
Providers should call the Prior Authorization Department at 1-866-212-2851 to request continuation of authorization for medically necessary services. You can also use our secure web portal. Or use the Prior Authorization form to request prior authorization via fax. Providers can fax a request to 1-855-320-8445 (toll-free).

Pharmacy
For non-formulary medications or formulary medications subject to certain limits (prior authorization, step therapy, quantity limits), providers should fax the Pharmacy Prior Authorization Request form and any medical records supporting continuation/use of the medication to 1-855-684-5250. Please note, the Pharmacy Prior Authorization Request form is different than the form for medical prior authorization and should be used any time a request for pharmacy prior authorization is needed. Failure to use the correct form may delay your request.

From the date a member first becomes effective with Aetna Better Health, the plan will provide up to a 90-day transition supply of medication(s). This transition supply will apply to medications that are either not on Aetna Better Health’s formulary or are on the formulary, but subject to prior authorization (PA) or other limits. Each time a member fills a 30-day supply of the transition medication, a letter will be sent to the member and provider. Before the 90-day transition supply ends, Aetna Better Health encourages providers to switch to a drug that is on Aetna Better Health’s formulary.

A case manager may call you to get specific information about member health care needs (i.e., medications prescribed, service information, etc.). A Transition of Care form is available online as well. Aetna Better Health may also request medical records.

Call Provider Services at 1-866-212-2851. Your call will be routed to our internal Transition of Care team when necessary.

Aetna Better Health encourages providers to electronically submit claims, through Emdeon. Please use the following Provider ID number when submitting claims to Aetna Better Health: 26337 for both CMS 1500 and UB 04 forms.

Contact your Provider Services representative for more information on electronic billing.

Or you can mail hard copy claims or resubmissions to:
Aetna Better Health
Claims and Resubmissions
P.O. Box 66545
Phoenix, AZ 85082

Resubmitted claims should be clearly marked “Resubmission” on the envelope.

Providers may review the status of a claim through our secure web portal or by calling our Claims Investigation Department at 1-866-212-2851.

Call Provider Services at toll free at 1-866-212-2851.