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Providing care

As our valued provider, your ability to serve our members is important. Aetna Better Health® of Illinois is here with information to help you provide care. This information is part of our Quality Improvement (QI) program, which is designed to address both the quality and safety of services provided to your patients who are also our members.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®)* survey is a chance for your patients to report their satisfaction with their health care, including their experience with their providers and health plans. The CAHPS survey scores are made available to the public and can determine whether patients and members stay with their providers or health plans or look elsewhere for their care. Surveys are sent to our members from February through June.

You are essential to providing health care to our members, and your satisfaction is important to us, too. We assess your experience with the health plan through an annual provider satisfaction survey. These survey results will be reviewed by Aetna Better Health of Illinois and will be key to helping us improve the provider experience. So, please be sure to complete the survey if you receive one. Surveys are sent to providers from October through December.

During the credentialing process, we obtain information from various sources to evaluate your application. Please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing (or recredentialing) application at any time by calling your health plan provider engagement representative.

If your address or telephone number changes, if you can no longer accept new patients, or if you are leaving the network, please notify us as soon as possible so we can update our provider directory. Having access to accurate provider information is vitally important to our members and we want to work together to make sure that continuity of care can be maintained for Aetna Better Health of Illinois members.

Utilization management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage.

 

Aetna Better Health of Illinois does not reward providers, practitioners or other individuals for issuing denials of coverage or care and does not have financial incentives in place that encourage decisions resulting in underutilization. Denials are based on a lack of medical necessity or a lack of a covered benefit. Nationally recognized criteria (such as interqual or MCG) are used, if available, for the specific service request, with additional criteria (such as clinical policies or medical policies) developed internally through a process that includes a review of scientific evidence and input from relevant specialists.

 

Submitting complete clinical information with the initial request for a service or treatment will help us make appropriate and timely UM decisions. You may discuss any UM denial decisions with a physician or another appropriate reviewer at the time of notification of an adverse determination. You may also request UM criteria pertinent to a specific authorization request or for any other UM-related request or issue by contacting the UM department at the health plan.

Providing care to our members includes helping adolescents transition to an adult care provider. If you or one of your patients need assistance in finding an adult primary care provider or specialist, contact Aetna Better Health of Illinois or reference the information in the provider manual. We can assist in locating an in-network adult care provider or arranging care, if needed.

The preferred drug list (PDL), also called the “health plan formulary,” is based on the plan benefits and is updated on a regular basis. The current PDL includes information regarding covered drugs, prior authorization requirements, limitations and more.


Read the PDL(PDF)

Our Care Management team is available for members who may benefit from increased coordination of services. The team is available to assist and support providers with member issues including nonadherence to medications and medical advice, multiple complex comorbidities, or to offer guidance with a new diagnosis.

 

The Care Management team helps members:

 

  • Achieve better health by managing their disease or condition

  • Determine and access available benefits and resources

  • Develop goals and coordinate with family, providers and community organizations to try to achieve them

  • Facilitate timely receipt of appropriate services in the right setting

 

Members can receive services through face-to-face visits, over the phone or in a provider's office. You can directly refer members to the Care Management program at any time by calling the health plan or initiating a referral on the Provider Portal. 


Visit the Provider Portal 

Every year, Aetna Better Health of Illinois assesses appointment availability for primary care physicians, specialists and behavioral health practitioners. There are established standards for each type of appointment (routine care, urgent visits and more) and type of practitioner. Please review the Provider Manual for the expectations of how quickly our members should be able to get an appointment.


Download the Provider Manual (PDF)

Providers are expected to understand and support member rights and responsibilities. Members are informed of their rights and responsibilities in their member handbook.

 

Member rights include but are not limited to:

 

  • Receiving all services that the health plan provides

  • Being treated with dignity and respect

  • Knowing their medical records will be kept private, consistent with state and federal laws and health plan policies 

  • Being able to see their medical records

  • Being able to receive information in a different format in compliance with the Americans with Disabilities Act (ADA)

 

Member responsibilities include:

 

  • Understanding their health problems and telling their health care providers if they do not understand their treatment plan or what is expected of them

  • Keeping scheduled appointments and calling the physician's office, whenever possible, if they are delayed or need to cancel

  • Showing their member ID card at appointments

  • Following the treatment plans and instructions for care that they have agreed on with their health care provider

 

We encourage you to refer to the Provider Manual to review the full list of rights and responsibilities.

*CAHPS® is a registered trademark of the U.S. Agency for Healthcare and Research Quality (AHRQ), which is part of the U.S. Department of Health and Human Services (HHS).

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