News & Notices

Stay up to date with all the latest notifications from Aetna Better Health of Ohio, and more.

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Aetna Better Health of Ohio's Online Prior Authorization Search Tool (ProPAT) Applicable to Aetna Better Health of Ohio, a MyCare Ohio Plan

ABH of Ohio is happy to announce that our Online Prior Authorization Search Tool (ProPAT) - which gives you the ability to look up codes to determine if they require Prior Authorization - is now available on our website with no log-in required.

Online Prior Authorization Search Tool

ABH of Ohio requires prior authorizations for select acute outpatient services and planned hospital admissions. Prior authorizations are not required for emergency services. To request a prior authorization, be sure to:

  • Always verify member eligibility prior to providing services.
  • Complete the appropriate authorization form (medical or pharmacy).
  • Attach supporting documentation when submitting. This could include:
    • Recent progress notes documenting the need for the service
    • Lab results
    • Imaging results (x-rays, etc.)
    • Procedure/Surgery reports
    • Notes showing previous treatment tried and failed
    • Specialty notes 

 

To check on the status of an authorization, please visit our Secure Web Portal.

For more information about prior authorization, please review ABH of Ohio's Provider Manual located under the Manual tab on our website.

You can fax your authorization request to 1-855-734-9389.

Important to Note: When checking whether a service requires an authorization under ABH of Ohio's Online Prior Authorization Search Tool, please keep in mind that a listed service does not guarantee that the service is covered under the plan's benefits. Always check plan benefits first to determine whether the service is covered or not. As always, don't hesitate to contact your ABH of Ohio Network Management Representative with any questions or comments. You can find this notice and all other provider notices on our For Providers tab on our ABH of Ohio website under News & Notices.

Thank you for all you do!

State of Emergency Provider Guide Statement on Telehealth Ohio Medicaid Managed Care Plans (MCPs) and MyCare (MMPs)   Coverage Expansion Overview

In order to ensure that all Ohio Medicaid members have needed access to care, the Ohio Department of Medicaid (ODM) and Medicaid Managed Care Plans (MCPs) are increasing the scope and scale of reimbursement for telehealth services for Medicaid recipients during the duration of the COVID-19 emergency. These coverage expansions will benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to reduce their exposure in public settings. Through collaboration with providers and ODM, the short-term goal of the MCPs is to expand access to critical patient care through the time of emergency, with the overarching goal of creating a future state centered on sustainability and person-centered quality metrics. 

This document serves as a simplified reference guide for Medicaid providers on the policies adopted by all MCPs centered on increasing access to evidence-based practices during the COVID-19 emergency. For specific details on reimbursement methods, filing claims and determining legal aspects of delivery of telehealth services, please refer to the ODM and individual MCP websites-links to the websites are included on the last page of this document.

Providers should follow state and federal guidelines regarding performance of telehealth services including permitted modalities.

This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. MCPs will use industry standard coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards.

Overarching Concepts

■ Any clinically appropriate service that can be delivered virtually will be eligible for telehealth coverage.

■ In accordance with state and federal guidelines, telehealth services may be delivered by providers with any connection technology to ensure patient access to care through permitted modalities.

■ Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth in accordance with state and federal guidelines.

■ Providers who have delivered care via telehealth should reflect it on their claim form by following standard telehealth billing protocols described by ODM.

■ Telehealth services apply to all individuals with Medicaid regardless of their status as a new or existing patient.  

Description

Telemedicine and telehealth are the direct delivery of services where the physician or other healthcare professional and the patient are NOT at the same location. These services are delivered using electronic communications, information technology or using other communication devices.

Definitions

■ Telehealth-An umbrella term for remote health care that may include health care education and administration as well as real-time clinical services.

■ Telemedicine-The direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. ■ Online visits-A real-time (synchronous), two-way communication that is initiated by the patient to virtually connect a physician or other health care provider for low complexity health care services.

■ Synchronous Telehealth-Real-time, interactive videoconferencing.

■ Asynchronous Telehealth-Activities that do not have both audio and video elements in the definition of interactive videoconferencing (telehealth); telephone calls, images transmitted through fax and electronic mail.

■ Asynchronous store and forward technologies-The transfer of a patient's medical information, through the use of a camera or recording device that is sent via telecommunication to another site for consultation.

■ Place of Service Codes (POS)-Codes that specifically indicate where a service or procedure was performed.

■ Telemedicine vendor-The participating telehealth vendor with a health plan that renders the telemedicine services. Health plans may use one vendor, multiple vendors or align with provider based vendors.

Prior-Authorization

Prior-authorization for telehealth service delivery is not required. Prior-authorization applies to the underlying service and not the use of telehealth as a mode of delivery. Providers who are not part of an MCP's participating network should check on prior-authorization requirements for services. (See health plan links and conditions of coverage below.)

Reimbursement

Telemedicine services are reimbursed according to Ohio Medicaid guidelines and using appropriate CPT and/or HCPCS and modifier codes. Please consult individual MCP reimbursement policies and ODM policies (links on the last page of this document.)  

Instruction

■ No place of service restrictions-allow any POS, including 99 (keep restriction on POS 09)(see For behavioral health agencies below).

■ No initial face-to-face visit is necessary to initiate services through telehealth. Where applicable, the requirement that an initial visit must be face to face is suspended.

■ Prior to providing services to a patient using telehealth, the provider should describe to the patient the potential risks associated with receiving treatment services via telehealth. The risks to be communicated to the patient should, at a minimum, include clinical aspects, security considerations and confidentiality of information when receiving services via telehealth.

■ Telemedicine providers are required to be licensed in the state where they are located and the state where the member is located. Providers can only bill for services within their scope of license.

■ The practitioner site should have access to the medical records of the patient at the time of service to the greatest extent possible and is responsible for maintaining documentation. If the medical record is not available, the practitioner site should create appropriate documentation and to the greatest extent possible, maintain existing documentation requirements.

■ MCP par and non-par providers can provide Telehealth services, but the provider must be participating with Ohio Medicaid.

■ If the practitioner site does not bill the MCP directly (i.e., holds a contractual agreement with the practice), the patient site or practice who holds the contractual agreement may instead bill for the service delivered using telehealth.

■ In such cases, the MCP's recommend the place of service (POS) code reported on the professional claim should reflect the location of the billing provider.

Note: Although telemedicine/telehealth service delivery does not require a prior authorization, the MCP may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity.

Where can Telehealth be provided?

Patient site-the patient site is wherever the patient is located. There is no limitation on the patient site except for penal facilities or public institutions such as jail or prison.

Practitioner site-the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth. There is no limitation on the practitioner site, except for penal facilities or public institutions such as jail or prison.

For behavioral health agencies certified by the Ohio Department of Mental Health and Addiction Services (OhioMHAS), allowable places of service are included in the BH provider billing manual.  

Eligible Providers

■ A professional medical group.

■ A professional dental group.

■ A federally qualified health center (FQHC) or rural health clinic (RHC) as defined in Chapter 5160-28 of the Administrative Code.

■ Ambulatory health care clinics (AHCC) as described in Chapter 5160-13 of the Administrative Code.

■ Outpatient hospitals.

■ Medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.

■ Private duty nurses.

■ Home health and hospice agencies.

Behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Ohio Administrative Code. Any practitioner listed as a rendering above, except for the following dependent practitioners:

■ Supervised practitioners and supervised trainees as defined in rule 5160-8-05 of the Administrative Code.

■ Occupational therapist assistant as defined in section 4755.04 of the Revised Code.

■ Physical therapist assistant as defined in section 4755.40 of the Revised Code.

■ Speech-language pathology aides and audiology aides as defined in section 4753.072 of the Revised Code.

■ An individual holding a conditional license as defined in section 4753.071 of the Revised Code.

■ Therapist who provide services on behalf of a Medicaid School Program (MSP) Provider. For the purpose of the Medicaid School Program, the school is the provider of record, who is responsible for billing Medicaid.

■ Licensed health professionals, such as respiratory therapists and athletic trainers, who are not enrolled as Ohio Medicaid providers but are employed or under contract with an enrolled provider to deliver critical support services.

■ Home health and hospice aide.

■ Registered Nurses (RN) and Licensed Practical Nurses (LPN) in the home health or hospice settings.

Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the appropriate Ohio Medicaid fee schedules.  

References

■ Ohio Administrative Code » 5160 Medicaid » Chapter 5160-1 General Provisions- 5160-1-18 Telehealth accessed on July 24, 2020. 

■ Ohio Department of Medicaid COVID-19 Emergency Telehealth Rules Summary of Updated Guidance accessed on July 24, 2020. 

■ Ohio Department of Medicaid Provider's Fee Schedule. 

Managed Care Plan Links  

■ Aetna 

Provider Notice: 10/16/2020 - Availability of Cares Act – Coronavirus Relief Fund – Provider Relief Payments 
 

Providers, please be aware that the State of Ohio has setup a Coronavirus Relief Fund Cares Act for Provider Relief Payment for which you may be eligible.  The deadline to apply is October 30, 2020.  

Please use Chrome to access the website.

 

Sincerely,

Aetna Better Health® of Ohio

Provider Notice 10/08/2020 - Hospital Rates Effective 7/01/2020 - Delayed

 

Dear Provider,

 

Aetna Better Health of Ohio (ABHO) recently discovered that hospital claims with dates of service on or after 07/01/2020 had been incorrectly paid using the old hospital rates. While Aetna updates these rates in its system, claims will be held to mitigate any additional inaccurate payments. Claims will be released once the update is complete, anticipated completion date is set for 10/07/2020. Aetna will also be creating a claims project for all affected claims that were processed incorrectly and will be sent for reprocessing. No actions are needed from providers that have been affected. If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact your provider liaison or Provider Services at 1-855-364-0974.

 

Sincerely,

 

Aetna Better Health of Ohio

 

Provider Services

Provider Notice 10/08/2020 – DME Underpayment

 

Dear Provider,

 

Aetna Better Health of Ohio (ABHO) recently identified a system configurations issue that was underpaying certain DME provider claims by 15% of the Medicare fee schedule. This issue impacted Medicare DME claims that were adjudicated on or after 7/19/2020. Claims billed on or after 9/30/2020 will be held until system is updated, claims that were adjudicated from 7/19/2020 to 9/29/2020 will be part of a claims project that will be reprocessed after configuration update. The anticipated completion date for configuration update is 10/30/2020. No actions are needed from providers that have been affected. If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact your provider liaison or Provider Services at 1-855-364-0974.

 

Sincerely,

 

Aetna Better Health of Ohio

 

Provider Services

Provider Notice 9/18/2020– Billing a Corrected Claim Reminder

Dear Provider,

Aetna Better Health of Ohio has started to see an increase in inaccurate billing when it comes to corrected claims. In many instances, the corrected claims have the incorrect originating claim listed that the provider is wanting to correct. As a result, the wrong claim is being reversed causing additional rework.

Best Practices

When submitting a corrected claim, validate the claim number that you are attempting to correct. Once validated place the claim number in box 22 of the 1500 claim form. Also, ensure you are using resubmission code 7 to identify this is a corrected claim.

If you are not sure of the claim number it is best to leave the field blank and insert a 7 for re submission code.

If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

 

Aetna Better Health of Ohio

Provider Services

Provider Notice 09/09/2020 – Waiver Code T1019 U4

 

Dear Provider,

 

Aetna has recently identified claims that did not appropriately process T1019 U4. These codes paid at a lower rate due to a configuration error.

 

If you have identified this type of incorrectly processed payment, no action is needed. Aetna has identified all effected claims and is working very quickly to have claims reprocessed. If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

 

Sincerely,

 

Aetna Better Health of Ohio

 

Provider Services

Provider Notice 08/27/2020 – COVID Lab codes U0001-U0004

 

Dear Provider,

 

Aetna has recently identified claims that did not appropriately process COVID lab codes U0001-U0004. These codes were denied with denial MA130- YOUR CLAIM CONTAINS INCOMPLETE AND/OR INVALID INFORMATION, AND NO APPEAL RIGHTS ARE AFFORDED BECAUSE THE CLAIM IS UNPROCESSABLE. PLEASE SUBMIT A NEW CLAIM WITH THE COMPLETE/CORRECT INFORMATION.

 

If you have identified this type of incorrectly processed payment, no action is needed. Aetna has identified all effected claims and is working very quickly to have claims reprocessed. If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

 

Aetna Better Health of Ohio

 

Provider Services

Provider Notice 08/13/2020 – SNF RUG claims 0120 billed with 0022

Dear Provider,

Aetna has recently identified claims that did not appropriately process SNF RUG claims when 0120 was billed with 0022. These claims bypassed Medicare line of business and only paid on the Medicaid line of business.

If you have identified this type of incorrectly processed payment, no action is needed. Aetna has identified all effected claims and is working very quickly to have claims reprocessed. If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

 

Aetna Better Health of Ohio

 

Provider Services

Provider Notice 06/29/2020 – 9921X E&M Codes

 

Dear Provider,

Aetna has recently identified claims that denied E&M codes 99211-99215 in error.

Remit messages include:

“This Procedure Code is inconsistent with the provider type/specialty (Taxonomy)”

“Invalid combination of HCPCS modifiers”

“The Procedure Code is inconsistent with the modifier used”

If you have identified this type of denial, no action is needed. Aetna has identified all effected claims and is working very quickly to have claims reprocessed. If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

Aetna Better Health of Ohio

Provider Services

Provider Notice 06/24/2020 – Par Hospice Providers billing T2046

 

Dear Par Hospice Provider,

Aetna has recently identified a configuration issue that when a  claim is received with a T2046 code from an in network hospice provider it is denying in error.  The remit denial message for these claims are "This provider type/provider specialty may not bill this service".  If you have identified this type of denial, no action is needed.  Aetna has identified all effected claims and is working very quickly to have claims reprocessed.  If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

Aetna Better Health of Ohio

Provider Services

Provider Notice – E & M Denial Issue (99441-99443)

 

Dear Provider,

Aetna has recently identified claims that denied in error when billing E & M codes 9944X. These claims were denying for coordination of benefits. Aetna has identified all affected claims and is working very quickly to have claims reprocessed.    

If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

Sincerely,

Aetna Better Health of Ohio

Provider Services

Provider Notification Update Effective May 31st, 2020 - COVID-19 Update: Prior Authorization, Pre-Certification and Admissions Protocol

Dear Provider,

Please see attached COVID-19 communication regarding Prior Authorization, Pre-Certifications and Admissions Protocol.

Thank You

COVID-19 Provider Outreach Survey

Dear Provider,

In response to COVID-19 there have been changes to support Aetna Better Health member’s and provider’s health and safety. Aetna Better Health of Ohio would like to get a better understanding of how our providers are handling the new regulations around Telehealth Services, Prior Authorizations, and Accessibility. Please consider taking this short survey.

https://www.surveymonkey.com/r/KXVCPM3

Thank you,

 Provider Services

Aetna Better Health® of Ohio

Provider Notice 05/12/2020 – H2019 LSW

Dear Behavioral Health Provider,

Aetna has recently identified claims that denied in error which impacted Licensed Social Worker (LSW) specialty types billing Therapeutic Behavioral Services H2019.

If you have identified this type of denial, no action is needed. Aetna has identified all effected claims and is working very quickly to have claims reprocessed.     

If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

Sincerely,

Aetna Better Health of Ohio

Provider Services

Provider Notice 05/12/2020 –Hospice Claim Payments

 Dear Hospice Provider,

Aetna has recently identified a system issue which resulted in Hospice claims (T2046) being paid at incorrect rates.  Aetna is currently working on updating its system with an estimated completion date of 05/31/2020, once complete all effected claims will be reprocessed with the appropriate rates going back to October 2019.

No action is needed by you the provider.

If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

Sorry for the Inconvenience,

Aetna Better Health of Ohio

Provider Services

PARTICIPATING PROVIDER NOTIFICATION – AUTHORIZATION CHANGES 

Dear Par Provider, 

Effective 07/01/2020, Aetna Better Health of Ohio will change the way the following HCPCS and or CPT codes will be processed. 

The first list of codes will no longer require prior authorization. 

The second list will require prior authorization and will be reviewed for medical necessity. 

As always, don't hesitate to contact your Aetna Better Health of Ohio Provider Relations Representative with any questions or comments.

Thanks for all you do!

Sincerely,

Provider Services

Aetna Better Health of Ohio

 

The following codes are changing from PA=Yes to No

0095T

Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)

0164T

Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)

0315T

Vagus nerve blocking therapy (morbid obesity); removal of pulse generator

0412T

Removal of permanent cardiac contractility modulation system; pulse generator only

0413T

Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)

0428T

Removal of neurostimulator system for treatment of central sleep apnea; pulse generator only

0429T

Removal of neurostimulator system for treatment of central sleep apnea; sensing lead only

0430T

Removal of neurostimulator system for treatment of central sleep apnea; stimulation lead only

0447T

Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision

0468T

Removal of chest wall respiratory sensor electrode or electrode array

0510T

Removal of sinus tarsi implant

0518T

Removal of only pulse generator component(s) (battery and/or transmitter) of wireless cardiac stimulator for left ventricular pacing

0530T

Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor)

0531T

Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only

0532T

Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only

15730

Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)

15733

Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)

19294

Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for primary procedure)

19328

Removal of intact mammary implant

19330

Removal of mammary implant material

19361

Breast reconstruction with latissimus dorsi flap, without prosthetic implant

19364

Breast reconstruction with free flap

19366

Breast reconstruction with other technique

27465

Osteoplasty, femur; shortening (excluding 64876)

27466

Osteoplasty, femur; lengthening

27468

Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer

32994

Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation

33275

Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography), when performed

47380

Ablation, open, of 1 or more liver tumor(s); radiofrequency

47381

Ablation, open, of 1 or more liver tumor(s); cryosurgical

47382

Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency

47383

Ablation, 1 or more liver tumor(s), percutaneous, cryoablation

50370

Removal of transplanted renal allograft

62355

Removal of previously implanted intrathecal or epidural catheter

81171

AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles

81172

AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status)

93644

Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)

95991

Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional

96127

Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument

A4641

Radiopharmaceutical, diagnostic, not otherwise classified

C1778

Lead, neurostimulator (implantable)

C1883

Ocular implant, aqueous drainage assist device

C1891

Infusion pump, nonprogrammable, permanent (implantable)

C1897

Lead, neurostimulator test kit (implantable)

C2624

Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components

G0293

Noncovered surgical procedure(s) using conscious sedation, regional, general, or spinal anesthesia in a Medicare qualifying clinical trial, per day

G0294

Noncovered procedure(s) using either no anesthesia or local anesthesia only, in a Medicare qualifying clinical trial, per day

G2000

Blinded administration of convulsive therapy procedure, either electroconvulsive therapy (ECT, current covered gold standard) or magnetic seizure therapy (MST, noncovered experimental therapy), performed in an approved IDE-based clinical trial, per treatment session

G9187

Bundled payments for care improvement initiative home visit for patient assessment performed by a qualified health care professional for individuals not considered homebound including, but not limited to, assessment of safety, falls, clinical status, fluid status, medication reconciliation/management, patient compliance with orders/plan of care, performance of activities of daily living, appropriateness of care setting; (for use only in the Medicare-approved bundled payments for care improvement initiative); may not be billed for a 30-day period covered by a transitional care management code

H0046

Mental health services, not otherwise specified

L7499

Upper extremity prosthesis, not otherwise specified

L8600

Implantable breast prosthesis, silicone or equal

L8625

External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each

L8689

External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

S2900

Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)

S8189

Tracheostomy supply, not otherwise classified

S9810

Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management, not otherwise classified, per hour (do not use this code with any per diem code)

 

 

The following codes are changing from PA=No to Yes

0508T

Pulse-echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibia

31661

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes

93355

Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg,TAVR, transcatheter pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D

H2030

Mental health clubhouse services, per 15 minutes

L5782

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy-duty

L6629

Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal

L6632

Upper extremity addition, latex suspension sleeve, each

L6680

Upper extremity addition, test socket, wrist disarticulation or below elbow

L6687

Upper extremity addition, frame type socket, below elbow or wrist disarticulation

L6881

Automatic grasp feature, addition to upper limb electric prosthetic terminal device

L6882

Microprocessor control feature, addition to upper limb prosthetic terminal device

L6890

Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment

L7007

Electric hand, switch or myoelectric controlled, adult

L7008

Electric hand, switch or myoelectric, controlled, pediatric

L7009

Electric hook, switch or myoelectric controlled, adult

L7040

Prehensile actuator, switch controlled

L7045

Electric hook, switch or myoelectric controlled, pediatric

L7185

Electronic elbow, adolescent, Variety Village or equal, switch controlled

L7186

Electronic elbow, child, Variety Village or equal, switch controlled

L7259

Electronic wrist rotator, any type

L7400

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultra-light material (titanium, carbon fiber or equal)

L7401

Addition to upper extremity prosthesis, above elbow disarticulation, ultra-light material (titanium, carbon fiber or equal)

L7402

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultra-light material (titanium, carbon fiber or equal)

L7403

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

L7404

Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

L7405

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material

L8604

Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies

L8607

Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies

L8631

Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)

P9604

Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated trip charge

T2013

Habilitation, educational, waiver; per hour

Provider Notification Update Effective May 7, 2020 - COVID-19 Update: Prior Authorization, Pre-Certification and Admissions Protocol

Dear Provider,

Please see attached COVID-19 communication regarding Prior Authorization, Pre-Certifications and Admissions Protocol.

Thank You

Temporary changes to prior authorization and admissions protocols for

Aetna Better Health of Ohio

Announcement summary:

Aetna Better Health of Ohio temporarily adopted changes to its prior authorization protocols for inpatient admissions to help health care facilities reduce administrative burdens during the COVID-19 pandemic. Additionally, Aetna Better Health of Ohio changed prior authorization requirements for post-acute care facilities, long-term acute care hospital admissions and acute care hospital admissions.

FAQs:

What changes is Aetna Better Health of Ohio making to its prior authorization and admission protocols?

Aetna Better Health of Ohio understands health care providers are experiencing increased demands due to the COVID-19 pandemic. To support our members and providers, Aetna is making temporary changes to its prior authorization protocols. Aetna Better Health of Ohio changed prior authorization requirements for post-acute care facilities, long-term acute care hospital admissions and acute care hospital admissions.

Does this liberalization apply to long-term care members moving from long-term care beds to skilled beds?

Aetna Better Health of Ohio’s temporary policy change is in place to reduce administrative burden on the acute care facilities and not delay discharges from the acute hospital facilities. If there is a potential need for a member living in a long-term care facility to move to a skilled level of care, our normal prior authorization policy applies.

Can a provider follow Aetna Better Health of Ohio’s standard UM prior authorization protocols instead of following the liberalizations that were put in place for the COVID-19 pandemic?

Aetna Better Health of Ohio is offering providers the flexibility to follow the standard process of submitting clinical information at the time of admission notification. Aetna will follow its current review process and issue a medical determination. For providers that are unable to submit clinical information at time of admission, Aetna will review those retrospectively unless prohibited by regulation.

Please see Aetna Better Health of Ohio’s UM liberalization notification (attached) to confirm which liberalizations apply in Ohio.

Do providers have to choose to follow either the standard UM prior authorization process or the liberalized protocol for the duration of the COVID-19 pandemic?

Aetna Better Health of Ohio is offering providers the flexibility, on a case by case basis, to follow Aetna’s standard or liberalized protocol so providers can determine which approach is appropriate for them given current circumstances.

How long will this process be in place?

Changes to reduce prior authorizations protocols for post-acute care and long-term acute care hospital admissions are effective through May 06, 2020.

Temporary changes to reduce prior authorizations protocols for acute care hospital admissions will be effective through May 06, 2020.

Aetna Better Health of Ohio will provide additional communication regarding any extension of policy changes.

What is required by hospitals when a member is transferred to a different care setting?

Hospitals are required to supply a patient’s medical records to the post-acute setting when the patient is transferred.

What is required from the post-acute facility once a member is transferred to a different care setting?

The post-acute facility will need to notify Aetna Better Health of Ohio of the patient’s post-acute admission.

Why is Aetna Better Health of Ohio requesting medical records within three days for post-acute facilities?

By communicating medical records, Aetna Better Health of Ohio can continue to help providers manage patients and assist in the discharge planning process. Length of stay reviews will still apply.

Where can I find more information?

Providers should call their provider services representative for more information.

Provider Notification 3/27/20-Updated 04/14/2020 - COVID-19 Update: Prior Authorization, Pre-Certification and Admissions Protocol

 

Dear Provider,

Please see attached COVID-19 communication regarding Prior Authorization, Pre-Certifications and Admissions Protocol.

 

Thank you,

 

Provider Relations Department

 

 

Attention Medicaid-only Providers

In response to the COVID-19 pandemic and the state of emergency declared by Ohio Governor Mike DeWine on March 9, 2020, the Ohio Department of Medicaid (ODM) adopted emergency rule 5160-1-21, “Telehealth during a state of emergency.”

This rule enhances ODM’s telehealth policy and provides several flexibilities for providers and Medicaid-covered individuals in need of care.

ODM is releasing additional policy guidance and detailed billing guidelines related to this rule.

In collaboration with ODM, Aetna Better Health® of Ohio is committed to ensuring all providers are aware of the changes and updates on an ongoing basis. Please review the below information and resources.

ODM’s policy guidance further expands telehealth to the following:

Additional covered telehealth services:

  • Limited oral evaluation
  • Hospice home care and long-term care
  • Direct skilled nursing services in the home health or hospice setting
  • Services of home health or hospice aides
  • Additional occupational therapy, physical therapy, speech language pathology, and audiology services
  • End stage renal disease (ESRD) related services

 Additional covered rendering practitioner types:

  • Dentists
  • Registered Nurses and Licensed Practical Nurses working in a hospice or home health setting
  • Licensed and credentialed health professionals working in a hospital or nursing facility setting (see the question 14 in the updated FAQ document for additional information)
  • Home health and hospice aides

Additional covered billing provider types:

  • Professional dental groups
  • Home health and hospice agencies  

ODM’s billing guidelines detail the following:

  • For nearly all services, the telehealth changes resulting from the emergency rule will be implemented in claims processing systems on April 15, 2020 by Medicaid fee-for-service (FFS), Medicaid Managed Care Plans (MCPs), and MyCare Ohio Plans (MCOPs).
  • ESRD-related services and some skilled therapy services will not be implemented in the FFS, MCP, and MCOP claims processing systems on April 15. These services should be billed as if they were rendered face-to-face until the IT system changes are in place. Additional details about these services can be found in the billing guidance. ODM will communicate about the implementation date for these services in the near future.
  • Providers must maintain documentation of services delivered via telehealth prior to and after the IT system changes are made.
  • Once the IT system changes are implemented on April 15, 2020, to the extent possible, providers should comply with the new billing guidance.
  • Providers should maintain documentation to support any necessary exceptions to the billing guidance while working to provide access to care for individuals during this time of emergency.

The April 13 updates add to the March 2020 emergency telehealth rule, which implemented the following changes:

  • The definition of Telehealth now includes additional forms of communication during a state of emergency, including telephone calls, fax, email, and other communication methods that may not have audio and video elements.
  • Medicaid covered individuals can access telehealth services wherever they are located. This includes homes, schools, temporary housing, hospitals, nursing facilities, group homes, and any other location, except for a prison or correctional facility.
  • Eligible providers can deliver telehealth services from any location, including their own home offices and other non-institutional settings.
  • Individuals with Medicaid can access telehealth services without having an established relationship with a provider.
  • Medicaid is covering new types of rendering practitioners and billing providers for the services they deliver through telehealth.
  • Medicaid is covering many more services when they are delivered through telehealth, including a number of previously uncovered services that are covered by Medicare.
  • The emergency rule also adopts guidelines found in the Office of Civil Rights’ “Notification of HIPAA Enforcement Discretion for Telehealth Remote Communication During the COVID-19 Nationwide Public Emergency.”

The following documents released today will be helpful to providers implementing ODM’s expanded telehealth services:

 

Additional questions and feedback regarding Medicaid policy can be directed to medicaid@medicaid.ohio.gov

OhioMHAS-certified providers can contact BH-Enroll@medicaid.ohio.gov

Additional COVID-19 information and resources can be found at coronavirus.ohio.gov or by calling 1-833-4-ASK-ODH (1-833-427-5634).

March 2020

A Message to our Long Term Care Providers:

As the COVID-19 pandemic continues to evolve, the Managed Care and MyCare Ohio Plans recognize and value the work the provider community is doing daily to care for vulnerable Ohioans.

The Health Plans want to partner closely with you as you care for our members. In an effort to support ongoing collaboration, as well as provide simplicity in how you contact each Health Plan regarding members in LTC, each plan is supplying you with our contact information so that you can reach out to us with questions or needs.

A member of the Health Plan will be in regular contact to obtain information regarding member care needs. The goal of this outreach is to obtain updates about members and to provide support and assistance from the Health Plan for:

  • Coordinating needed resources
  • Linkage to community services
  • Discharge planning for members seeking return to the community
  • Determining proper level of care for members while face to face contact is not an option

 

As the Health Plans reach out to collaborate on our LTC members, please let us know your preferred communication method and/or point person to communicate with for any continued LTC needs during the pandemic. Health Plans encourage you to contact the appropriate Plan(s) for needs or questions regarding any resident(s).

The preferred contact information for the Health Plans are:

Aetna: Andrea Price, LTSS Director, PriceA4@aetna.com

            Kendra Marks, UM Director, MarksK4@aetna.com

 

Provider Notification 3/25/20 - Rate increase for Assisted Living, Passport, and Ohio Homecare Waiver

 

Dear Provider,

 

Aetna has updated its Ohio home care waiver program reimbursement rates and billing procedures to accurately reflect the amendment filed on 3/13/2020 by The Register of Ohio.  You can review the amendment here.

 

Please be sure that your claims include the updated rate. If you have previously submitted a claim with an incorrect rate, you will need to submit a corrected claim to be processed accurately. If you have any questions or concerns, please contact Aetna Ohio Provider Services at 1-855-364-0974.

 

Thank you,

 

Provider Relations Department

Provider Notification 3/24/2020 - Updates to Evaluation & Management (E&M) Code Billing  

Dear Provider,

Aetna Better Health® of Ohio continues its commitment to correct coding and the implementation of programs that support nationally recognized and accepted coding policies and practices. Evaluation and Management (E&M) coding is an area that the Centers for Medicare & Medicaid Services (CMS) has identified as having significant error rates.

What does this change mean for my office?

Starting with claims for dates of service on or after January 1st, 2019, we will evaluate the appropriateness of E&M coding reported using CMS and AMA documentation guidelines for Office Visit codes:

  • New Patients CPT codes 99201-99205,
  • Established Patients CPT codes 99211-99215, and
  • Office Consultations codes 99241-99245.

 

Based on the outcome of this evaluation, your payment may be adjusted if the information submitted on the claim does not support the level of service billed.

If your claim is adjusted for this reason, you will see the following remittance information:

  • CARC 252 - an attachment/other documentation is required to adjudicate this claim/service
  • RARC M127 - missing patient medical record for this service
  • N183 - ALERT: - this is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.

                                                    

Can I dispute a denial?

If you do not agree with a specific payment determination, you have the right to file a clinical editing dispute to this address:

Aetna Better Health of Ohio

Attn: Claims Department

PO Box 64205 Phoenix, AZ 85082-2198

 

 

As part of your dispute, you must submit the portion of the medical record that contains documentation to support the level of service you reported. We will review the submitted medical records to assess the intensity of service and complexity of medical decision-making for the E&M services reported.

Aetna Better Health may adjust those claims where documentation substantiates the provision of a higher level of E&M service.

Aetna Better Health will evaluate this program periodically based on billing trends and may make adjustments as necessary.

Questions?

Please direct any questions regarding this change to your Provider Relations rep or by calling Provider Services at 1-855-364-0974.

 

Sincerely,

 

Provider Services

Aetna Better Health® of Ohio

 

 

PROVIDER NOTIFICATION 3/23/2020 – UPDATE ON STERILIZATION CODES REVIEW AND PAYMENT

 

Dear Provider,

 

Effective May 1, 2020 Aetna Better Health of Ohio will change the way sterilization related CPT and HCPCS codes are reviewed and paid.

These codes will no longer be managed through the prior authorization process. They will be managed by submission of the following:

  1. A copy of a signed Consent for Sterilization Form at the time of claim submission for members age 21 and older , OR for hysterectomy, a completed Hysterectomy Necessity Form, OR;
  2. Documentation of the following:
    1. The procedure was performed on a member who is sterile as the result of conditions such as (not an all-inclusive list);
      • a prior surgery
      • menopause
      • prior tubal ligation
      • pituitary or ovarian dysfunction
      • pelvic inflammatory disease
      • endometriosis or congenital sterility, OR;
    2. The procedure was performed in a life-threatening emergency in which a physician determines that prior acknowledgment was not possible.

 

Codes eligible for this process:

 

Code                     Code Description

 

55250

Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)

 

58150

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);

 

58152

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch)

 

58180

Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

 

58200

Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)

 

58210

Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)

 

58240

Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof

 

58260

Vaginal hysterectomy, for uterus 250 g or less;

 

58262

Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)

 

58263

Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

 

58267

Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

 

58270

Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

 

58275

Vaginal hysterectomy, with total or partial vaginectomy;

 

58280

Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele

 

58285

Vaginal hysterectomy, radical (Schauta type operation)

 

58290

Vaginal hysterectomy, for uterus greater than 250 g;

 

58291

Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

 

58292

Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

 

58293

Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

 

58294

Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

 

58340

Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography

 

58541

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;

 

58542

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

 

58543

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;

 

58544

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

 

58545

Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas

 

58546

Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g

 

58548

Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed

 

58550

Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;

 

58552

Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

 

58553

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;

 

58554

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

 

58559

Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)

 

58565

Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants

 

58570

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;

 

58571

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

 

58572

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;

 

58573

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

 

58575

Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed

 

58600

Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral

 

58605

Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)

 

58611

Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure)

 

58615

Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach

 

58661

Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)

 

58670

Laparoscopy, surgical; with fulguration of oviducts (with or without transection)

 

58671

Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)

 

58700

Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)

 

58720

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;

 

58740

Lysis of adhesions (salpingolysis, ovariolysis)

 

58940

Oophorectomy, partial or total, unilateral or bilateral;

 

58950

Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy;

 

58951

Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy

 

58952

Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors)

 

58953

Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking;

 

58954

Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy

 

58956

Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy

 

58957

Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed;

 

If you have additional questions regarding this process please contact claims inquiry/claims research staff at 1-855-364-0974 or work with your assigned Provider Relations Liaison.

Sincerely,

Provider Relations

Dear Providers, 

Aetna Better Health of Ohio would like to inform you that effective 3/26/2020 our Provider/ Member Grievance and Appeals mailing address will change. 

Participating Providers

This will not affect the participating provider dispute process which Participating Providers submit claims disputes to:

AETNA BETTER HEALTH OF OHIO

P.O. BOX 64205

PHOENIX, AZ 85082

 

Non Participating Providers / Members

We kindly ask that you update your records accordingly and to address all future Grievances and Appeals to our new mailing address as followed:

Non Participating Provider Grievance & Appeals NEW address

Aetna Better Health of OHIO

PO Box 81040

5801 Postal Road

Cleveland, OH 44181

Member Grievance & Appeals NEW address

Aetna Better Health of OHIO

PO Box 81139

5801 Postal Road

Cleveland, OH 44181

Attached you will find the link to our Provider Manual which will help you with your claim questions and concerns. It also includes information regarding reconsiderations, claims inquiry, disputes and appeals. 

https://www.aetnabetterhealth.com/ohio/providers/manual

The dispute and appeal forms can be found on our Aetna Better Health of OHIO website for your convenience. 

https://www.aetnabetterhealth.com/ohio/providers/forms

We appreciate the excellent care you provide our members. If you have any questions, please feel free to contact us via e-mail: OH_ProviderServices@aetna.com. You can also call us through our Provider Relations telephone line: 1-855-364-0974

Thank you,

 

Provider Relations Department

03/13/2020

Dear Provider, 

Aetna Better Health of Ohio has expanded services with Equian, Cotiviti and Optum to further enhance our payment integrity program in accordance with expectations set forth by our various state Medicaid partners.

Equian will be reviewing claims for proper coding of facility claims against the final medical record available post discharge to ensure that proper payment is being made in accordance with our contracts, national coding guidelines and nationally accepted billing guidelines. This program will result in an outreach to arrange for release of medical records.  In addition, Equian will identify claim overpayments, including retro-terminations, utilizing data mining techniques to validate claim payments for facility and professional claims against provider contracts, Aetna policy and regulatory guidance provided by the state.

In addition to services already performed by Cotiviti, Aetna will partner with Cotiviti to identify instances of other third-party liability primary, specifically Coordination of benefits with other carriers and Medicare.  As part of the program, there will be letters sent to your attention that contain the other carrier's information that will include name of carrier, member number and applicable effective dates. Medicaid is the payer of last resort and the information provided should be used to file immediately upon receipt with the other carrier to prevent exceeding timely filing limits.  If timely filing has been exceeded with the other carrier, please file the claim with proof of timely filing with Aetna as most carriers consider this as an appropriate reason to override timely filing.

Aetna Better Health of Ohio wants to ensure that our hospital providers can take advantage of Hospital Credit Balance services offered by multiple suppliers in the industry that can assist with returning overpayments to Aetna Better Health.  For that reason, we will be adding Optum as an option where our current supplier does not have access to your facility.  Optum will be assigned facilities by Aetna Better Health and will contact you regarding review of our member accounts at your convenience.}

In compliance with the HIPAA Privacy Rule, Aetna Better Health of Ohio has entered into a Business Associate Agreement (BAA) with the above-mentioned suppliers. The Privacy Rule allows a covered entity to share information with another covered entity's business associate as if the request came from that other covered entity.

 

Thank you for your cooperation,

 

Provider Services

Aetna Better Health® of Ohio

02/12/2020

Dear Provider:

We are pleased to announce that Aetna Better Health of Ohio and NantHealth have partnered to give you access to Eviti Connect, an online software system that enables real-time decision support and treatment guidelines for oncology patients.

Effective on or after April 20, 2020, there will be a change of process for initiating oncology treatment plan review requests. Below is a summary of these changes:

Overview of Process Change 

Purpose of Eviti Connect

To provide specialist review of oncology treatment plans including chemotherapy, radiation therapy and supportive medications

Uses of Eviti Connect

·         Access to the latest evidence-based guidelines for radiation and chemotherapy

·         Select from 3,800+ pre-built regimens, or customize treatments when necessary

·         Discuss open treatment plan reviews with Eviti’s clinical staff

Treatment Recommendations

Eviti Connect aggregates evidence-based recommendations from national government agencies, reports, and journal publications (including the NCCN Compendium, JCO, JNCI, Lancet, NEJM and JAMA)

Training

Early April 2020: Several training sessions will be available to help you become familiar with using Eviti Connect to submit treatment plan reviews. The training schedule will be sent in a future communication.

New Process Effective Date

On or after April 20, 2020

 

All oncology treatment plans will be submitted to NantHealth via their web portal, Eviti Connect (https://connect.eviti.com/), which will expedite review of any chemotherapy, radiation therapy, or supportive medications. 

Training for Eviti Connect

Training courses are available so your office can learn how to get the most from this program. You can also access https://help.eviti.com/ to view the Eviti Connect user guide, video tutorials, and interactive eLearning modules.

These are web-based, instructor-led, interactive training sessions that will guide you through the process of creating an account and submitting treatment plans. You will need access to the internet to view the training. Anyone in your office responsible for submitting treatment plans for review should plan to attend one of these sessions. The schedule is below.

Radiation Training Times

4/2/2020

2:00 PM ET

4/7/2020

11:00 AM ET

4/9/2020

2:00 PM ET

4/14/2020

2:00 PM ET

4/15/2020

11:00 AM ET

4/16/2020

2:00 PM ET

4/20/2020

11:00 AM ET

Chemotherapy Training Times

4/2/2020

11:00 AM ET

4/7/2020

2:00 PM ET

4/9/2020

11:00 AM ET

4/14/2020

11:00 AM ET

4/15/2020

2:00 PM ET

4/16/2020

11:00 AM ET

4/20/2020

2:00 PM ET

To register, send an email to training@nanthealth.com and indicate which training session you wish to attend and the number of attendees (if more than one) from your office who will participate. We will respond with details for that web training session – including a toll-free phone number and a link to the web portion of the conference.

Please keep the training registration e-mail so you will have the link to the web conference and the call-in number for the session in which you will be participating. 

About Eviti Connect’s Web Portal 

Using the Eviti Connect web portal is the fastest and most efficient way to initiate a treatment plan review.

Typically, treatment entry takes less than 15 minutes, and treatments that comply with evidence-based standards receive an “Eviti code.” This means that the treatment plan submitted by you meets national standards of quality care and the definition of medical necessity as determined by Aetna Better Health of Ohio.

Please note that this Eviti code is not an authorization reference number and is not a guarantee of payment. However, the generation of an Eviti code initiates an authorization request with Aetna Better Health of Ohio who will complete the authorization process and issue the final determination and your reference number.

If you do not receive an Eviti code instantly, Eviti’s Medical Office can review and discuss the treatment with your office before referring it to Aetna Better Health of Ohio for final determination.

 

To Create an Eviti Account

 

You can create an account and submit your treatment plans through the Eviti web portal:

https://connect.eviti.com/Connect

 

For Additional Information or Support

Phone:   1-888-482-8057 (Select option #2)

Email:   clientsupport@nanthealth.com

If you have any questions regarding the implementation of this program, we encourage you to contact Aetna Better Health of Ohio for additional information, support, and training at 855-364-0974.

We look forward to working with you on this new process!

 

Sincerely,              

William Flood, M.D.                            

Chief Medical Officer                          

NantHealth, Eviti                               

February 13, 2020

Dear Provider,

It's time again to collect data for the Healthcare Effectiveness Data and Information Set (HEDIS®).  Each year we collect medical record data on a sample of our members in your care as part of the nationwide collaborative effort among employers, health plans and physicians.  HEDIS is one of the most widely used sets of health care performance measures in the United States.  The goal is to monitor and compare health plan performance on specific performance measures.   We will be contacting you soon to request these medical records.  Your participation and timely response to our medical record request is key to the success of the project.

We understand your concerns about confidentiality and releasing medical records. Be assured that our data collection efforts comply with Health Insurance Portability and Accountability Act (HIPAA) regulations.  All of the information is kept confidential. We only use the data in an aggregate form and do not release patient-specific information.  Our members are made aware of our quality programs and how we manage confidentiality and privacy through their member handbook.  We do not require a member's signature to release this information as the health care operations exception under HIPAA allows this activity.

Minimum Documentation Requirements

All records must include:

  1. The patient's name on every page of documentation.
  2. The patient's date of birth on at least one page of documentation.
  3. The information requested for each measure (which will be included with the member list that will be faxed to you at the beginning of the project).

*Please do not send calendar year 2020 information.

We look forward to working with you again this year on this project.  Please contact our HEDIS Help Line at 855-750-2389 and leave a voicemail, if you have any questions about the upcoming HEDIS project. A member of the HEDIS team with respond to your voicemail as quickly as possible.

HEDIS Data Submission via Provider Portal

Aetna Better Health of Ohio providers are able to upload medical record documentation for HEDIS securely through our provider portal.  Instructions on how to use the provider portal for HEDIS data submission will be sent out to providers upon request. Please contact our HEDIS Help Line at 855-750-2389 and leave a voicemail with your email address and contact information and a step by step guide on using the Provider Portal for HEDIS Data Submission will be sent to you.

 

For more information visit our website at https://www.aetnabetterhealth.com/ohio or click here to fill out the Web Portal Registration Form if you are a new user.

Call us at 1-855-364-0974, option 2, or email us at OH_ProviderServices@aetna.com if you have additional questions regarding this communication.

 

HEDIS® Provider/Facility Frequently Asked Questions

  1. What is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most widely used sets of health care performance measures in the United States. It is developed and maintained by the National Committee for Quality Assurance (NCQA). The HEDIS methodology provides a systematic and standardized way for health plans to document how well they provide health care services to enrolled members. Health plans have the option of calculating HEDIS rates by using the administrative data methodology or the hybrid methodology. The administrative data methodology is limited to the use of claim and encounter data submitted to the health plan. The hybrid methodology includes claim and encounter data, but also uses data obtained directly from the member’s medical record. This allows the health plan to count services where claim or encounter data were not received.

Use of medical record data requires that we obtain a copy of the member’s medical record. Each record should include the member name, gender and date of birth to confirm that the correct record has been obtained. The copy should be limited to required documentation and demographic information.

What is needed from your practice/office/facility?

A response to Aetna MyCare Ohio’s requests for medical record documentation in a timely manner and access to designated patient medical records so that the HEDIS staff can do one of the following:

  • Scan patient medical record medical records to a secure server
  • Put Electronic Medical Records (EMR) on a secure encrypted flash drive
  • Take photos of medical record on an encrypted iPod and send to secure server
  • Make paper copies

What is being measured?

 

The following HEDIS measures allow the use of medical record documentation to supplement claims/encounter data:

  • Adult BMI Assessment
  • Care for Older Adults
  • Colorectal Cancer Screening
  • Comprehensive Diabetes Care
  • Controlling High Blood Pressure (not applicable to nursing homes/skilled nursing facilities)
  • Medication Reconciliation Post Discharge
  • Transitions of Care

 

When will the Aetna MyCare Ohio HEDIS staff need the records?

 

HEDIS data collection is a time sensitive project. Medical records should be made available on the date of the onsite review, or by the date requested, in the case of upload/fax/mail. Typically, data collection begins in mid-February and ends in late April.

It is imperative that you respond to a request for medical records within five (5) business days to ensure we are able to report complete and accurate rates to state and federal regulatory bodies, as well as NCQA.

Do HIPAA Rules apply?

Yes, all of our nurses will be trained by the health plan on HIPAA, Confidentiality and handling Personal Health Information (PHI) prior to going to provider offices.

Does HIPAA permit me to release records to Aetna My Care Ohio for HEDIS Data Collection?

Yes. You are permitted to disclose PHI to Aetna MyCareOhio. A signed consent from the member is not required under the HIPAA privacy rule for you to release the requested information to Aetna MyCare Ohio. Aetna Mycare Ohio is a managed care plan contracted with the Ohio Department of Medicaid (ODM, www.medicaid.ohio.gov) which administers the Ohio Medicaid program and the Centers for Medicare and Medicaid Services (www.cms.gov) which administers the federal Medicare program. The member’s enrollment into both of these programs gives consent for the plan to review their medical records for quality purposes

Who will be reviewing medical records?

Aetna contracts with nurses to perform the medical record abstraction for the HEDIS project. The nurses go through a thorough training on HEDIS medical record abstraction and everything it entails including HIPAA and PHI. The Aetna MyCare Ohio HEDIS staff will be contacting each office directly to set up an appointment to review the medical records. They will send a patient list via fax or email prior to the agreed upon appointment. Staff are instructed to be flexible in making the appointment time that works for your office staff.

 

 

Is my participation in HEDIS data collection mandatory?

Yes. Network participants are contractually required to provide medical record information so that we may fulfill our state and federal regulatory (i.e., Ohio Department of Medicaid and the Centers for Medicare and Medicaid Services) and National Committee for Quality Assurance (NCQA) accreditation obligations.

 

 

How am I (provider) measured?

HEDIS is NOT a measurement of individual providers, nor how they keep their medical records. It’s a measurement of how the health plan is performing to get their members needed services such as immunizations or well child visits. No reports will be given on a specific provider. Aggregated results of the health plan will be shared with CMS, ODM, and NCQA.

 

What Aetna MyCareOhio membership is included in HEDIS? 

 

HEDIS data collection pertains to members enrolled in the MyCareOhio program for members with both Medicare and Medicaid managed by Aetna Better Health of Ohio.

 

Should I allow a record review for a member who is no longer with Aetna MyCare Ohio or for a member who is deceased?

 

Yes. Medical record reviews may require data collection on services obtained over multiple years.

Am I required to provide medical records for a member who was seen by a physician who has retired, died, or moved?

Yes. HEDIS data collection includes reviewing medical records as far back as 10 years. Archived medical records/data are required to complete data collection.

Will I be reimbursed for copies/materials?

Per the standard contract as a participating provider with Aetna MyCare Ohio, we do not reimburse for medical record copies requested for HEDIS data collection. If you have additional questions, please consult your participation agreement or talk to your Aetna MyCare Ohio network representative. Aetna MyCare Ohio HEDIS staff who conduct reviews onsite have scanning capabilities that create a digital image, making record copying unnecessary.

 

 

Who should I contact if I have further questions/concerns regarding HEDIS Data Collection?

Please contact our HEDIS Help Line at 855-750-2389 and leave a voicemail, if you have any questions about the upcoming HEDIS project. A member of the HEDIS team with respond to your voicemail as quickly as possible. 

For more information on HEDIS, you can visit NCQA’s website at www.ncqa.org/HEDISQualityMeasurement.aspx

 

Sincerely,

 

Provider Services

Aetna Better Health® of Ohio

Provider Notice 02/04/2020 – 30 Day Readmission

Dear Provider,

Aetna Better Health of Ohio would like to remind you of the proper billing practice for readmissions.

In alignment with CMS readmission guidelines we expect that providers will need to submit corrected claims as necessary when members re-enter the hospital within 30 days of discharge from a previous admission. Aetna will pay the initial claim according to the initial requested authorization as submitted.   If the member is readmitted, the provider should submit a corrected claim inclusive of the original and second admission with leave of absence codes during the timeframe the member was not admitted. Upon receipt of the corrected claim, Aetna will retract the original payment and consider the new corrected and comprehensive claim for payment. Note that authorizations for a member readmission will be denied under the previous stay which occurred within the last 30 days. It is not Aetna’s intention to deny payment for the readmission, however system edits will deny inpatient readmissions unless the claim is submitted as a corrected claim.   The claim should include the leave of absence revenue code to indicate the days the member was not inpatient. Note, this corrected claim will have two authorizations 1 which is approved and 1 which is denied. Aetna will accept the corrected claim and reverse the original paid amount and process the new corrected claim accordingly.   Please note you cannot resubmit only the corrected/denied lines, the complete corrected claim must be submitted.

If you have not yet submitted the claim for the original admission by the time the member is readmitted Aetna expects that you will forgo submitting separate claims and will combine the former admission with the readmission into one claim again utilizing the LOA revenue codes for the days not inpatient.   This avoids the need for submitting the original claim, and then the corrected claim.

If you have additional questions regarding this process please contact claims inquiry/claims research staff at 1-855-364-0974 or work with your assigned Provider Relations Liaison.

Sincerely,

Provider Relations

OhioMHAS Waiver Trainings

 

To help address the opioid crisis in the state of Ohio, the Ohio Department of Mental Health and Addiction Services is offering free DEA DATA 2000 waiver trainings. Below you will find general information on these trainings and how to register.

 

This is a free 1.5-day training. Training is open to all physicians, nurse practitioners and physician assistants who hold an Ohio license and a current DEA number. Physicians who attend the 1.5-day training, obtain their waiver, and fulfill reimbursement criteria will receive $1,300. Nurse practitioners and physician assistants who attend the 1.5-day training, complete an additional online component, obtain their waiver and fulfill reimbursement criteria will receive $750. All attendees will also receive free CMEs. 

 

OhioMHAS has awarded a grant to ASAM to provide trainers for the first day of the waiver training.  The second day focuses on implementation of MAT into practice. For the second day there will be a waivered physician speaking on implementation of MAT into practice and answering any questions, an OhioMHAS training officer will present information on SBIRT and motivational interviewing, and a local provider will present referral to treatment and available resources in the local area.

 

The link below goes to the workforce development page at OhioMHAS.  

 https://mha.ohio.gov/About-Us/Grants-and-Funding/Federal-Funding/CURES-Act/Data-2000-Prescriber-Training-for-MAT

 

Dates

Location

Room

 

Registration Link

1/15-16

Genesis Health Plex

2800 Maple Avenue

Zanesville, OH

 

Conference Room C at the back of the building

Free Parking

 

 

https://elearning.asam.org/products/asamohio-waiver-training-zanesville-ohio-january-15-16-2020#tab-product_tab_overview

 

2/6-7

Cleveland Clinic South Pointe Hospital

Warrensville Hts., OH

 

B auditorium

Free Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-warrensville-heights-ohio-february-6-7-2020

 

2/7-8

University of Cincinnati

231 Albert Sabin Way

Cincinnati, OH

 

Medical Science Bldg. Room 5051

Free Parking

 

 

https://elearning.asam.org/products/asamohio-waiver-training-cincinnati-ohio-february-7-8-2020#tab-product_tab_overview

 

2/28-29

Romer’s Catering Center

1100 S. Main Street

Celina, OH

 

Meeting Room

Free Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-celina-ohio-february-28-29-2020#tab-product_tab_overview

 

3/12-13

Ohio State University

360 W. 9th Ave.

Columbus, OH

 

Meiling Hall 160

Garage Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-columbus-ohio-march-12-13-2020#tab-product_tab_overview

 

3/26-27

Ohio Health

3430 Ohio Health Parkway

Columbus, OH

 

 Free Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-columbus-ohio-march-26-27-2020#tab-product_tab_overview

 

3/27-28

Mercy Health

St. Anne Hospital

3404 W. Sylvania Ave.

Toledo, OH

 

Meeting Room 3

Free Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-toledo-ohio-march-27-28-2020#tab-product_tab_overview

 

4/13-14

MetroHealth

2500 Metro Health Drive

Cleveland, OH

 

Scott’s Auditorium

Free Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-cleveland-ohio-april-13-14-2020#tab-product_tab_overview

 

4/20-21

Metro Health

2500 MetroHealth Drive

Cleveland, OH

 

Scott’s Auditorium

Free Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-cleveland-ohio-april-20-21-2020#tab-product_tab_overview

 

4/27-28

Ohio State University

32 W. 10th Ave

Columbus, OH

M100 Starling Loving Hall

Garage Parking

 

https://elearning.asam.org/products/asamohio-waiver-training-columbus-ohio-april-23-24-2020#tab-product_tab_overview

 

 

Provider Notice PN200116-001

 

 

 

 

 

OTP Provider,

On 12/27/2019, CMS released a HPMS memo titled “Addressing Continuity of Care for Dually Eligible Enrollees Currently Receiving Opioid Treatment Program Services through Medicaid”. This memo outlines the implementation of the Medicare Opioid Treatment Program (OTP) benefit effective January 1, 2020. Medicare became the primary payer for dually eligible enrollees who may previously have obtained these services through Medicaid.

This change from Medicaid to Medicare is significant in that most OTP providers are not Medicare Certified providers. CMS wants to ensure continuity of care for dual eligible enrollees and ensure payment is made to OTP providers, during this transition. This will allow OTP providers time to become certified with Medicare for OTP Services.  To become OTP Medicare Certified please refer to this comprehensive OTP Medicare Enrollment Fact Sheet provided by CMS:

https://www.cms.gov/files/document/otp-medicare-enrollment-fact-sheet.pdf

If you require additional assistance you should contact SAMHSA or your MAC directly as outlined in the OTP Medicare Enrollment Fact Sheet.

Aetna Better Health of Ohio will ensure that all members continue to receive OTP services by ensuring providers are paid through this transition.  CMS issued a bulletin to the State Medicaid Agencies on 12/17/19 stating the states must continue to pay for OTP services until the OTP providers can become Medicare certified. Based on Medicare guidance Aetna Better Health of Ohio is giving providers two choices for future claims submission:

  1. Hold claims using Medicare OTP codes until your organization is OTP Medicare certified. Providers who choose this option must continue to serve dual members and ensure continuity of care.
  2. Continue to submit and be reimbursed for Medicaid OTP claims. Once you have received OTP Medicare Certification, Aetna Better Health of Ohio requests that you then begin to use the new OTP Medicare codes. Aetna Better Health of Ohio will then perform recoupment of claims that were paid under Medicaid for OTP services back to the provider’s Medicare effective date, but no further than 1/1/2020. Providers will then submit corrected claims with the new Medicare OTP codes.  

Please note if your organization submits claims with the new Medicare OTP codes prior to OTP Medicare Certification then these claims will be denied.

If your organization has previously submitted claims to Aetna Better Health of Ohio, Aetna Better Health of Ohio will update your provider record in our system once you appear as a Medicare certified provider on the Data.CMS.gov site: https://data.cms.gov/Medicare-Enrollment/Opioid-Treatment-Program-Providers/t5tg-crb5 Please allow up to 30 days from the date your organization appears on the site for Aetna Better Health of Ohio to update your provider information.    

Aetna Better Health of Ohio encourages your organization to submit your Medicare Application as soon as possible as the process can take some time.   CMS has not yet set a firm date for mandatory provider OTP Medicare Certification, however CMS has stated that this process should only occur through ‘early 2020’. Based on this language Aetna Better Health of Ohio anticipates CMS to issue a date by which all OTP providers must be certified.

For more information on these OTP changes please review the following:

CMCS Informational Bulletin 12/17/2019

  • Guidance to State Medicaid Agencies on Dually Eligible Beneficiaries

 

Receiving Medicare Opioid Treatment Services Effective January 1, 2020

https://www.medicaid.gov/federal-policy-guidance/downloads/cib121719.pdf

HPMS Memo 12/27/2019 Corrected 1/2/2020

Addressing Continuity of Care for Dually Eligible Enrollees Currently Receiving Opioid Treatment Program Services through Medicaid

https://www.cms.gov/files/document/otp-hpms-memo-122719-correction.pdf

 

If you have questions please refer to the sources attached in this letter or the FAQs below. If you have further questions you can contact Aetna Better Health of Ohio Provider Services at 1-855-364-0974.   Thank you for your attention to this matter.

 

Sincerely,

Aetna Better Health of Ohio

Provider Experience

 

FAQS

What are the new Medicare OTP codes?

The code range is G2067-G2080. For more information refer to : https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Opioid-Treatment-Program/billing-payment

We billed a claim with a new OTP G code. Why hasn’t my organization received payment yet?

  • If you are not OTP Medicare Certified then you are not aligned to a contract that is able to pay your claim yet. You should have billed your claim for OTP services as you have for Medicaid. Once OTP Medicare certified, your claims will be recouped and you will submit a corrected claim under Medicare guidelines at that time.
  • If you are Medicare Certified then your provider record is in the process of being updated. Your claim is pending and will be released once your record is updated to allow for Medicare payment.

How should my organization bill?

Bill your claims based upon your organizations current Medicare certification status. Bill as you have for Medicaid until you have confirmation of your Medicare certification Effective date. If you are Medicare certified do not submit any more claims under Medicaid billing practices instead use the new Medicare OTP codes for all claims on or after your OTP Medicare certification.

Should my organization hold claims?

It is up to your organization. Aetna does not recommend holding claims because it can take time to complete the Medicare Certification process. Aetna recommends continuing to bill OTP services as you have under the Medicaid program to keep payment coming in for the services you are providing to our members. Aetna will recoup all the Medicaid paid claims back to your Medicare effective date and once you submit your corrected claims under Medicare the negative balance will be offset.

Does my organization need to resubmit claims?

Yes, after Medicare certification is received Aetna Better Health of Ohio will recoup the claims processed under Medicaid and you will need to submit a corrected claim with the appropriate OTP Medicare codes.

 

Does my organization need to submit a separate Medicaid claim to Aetna?

No, Aetna’s crossover claim process will run producing a secondary claim after the Medicare primary claim processes. Should you submit a separate Medicaid claim it will deny as a duplicate against the Aetna created crossover Medicaid claim.

Does my organization need to become Medicare certified?

No, however if you serve a member who is Dually Eligible, please note that we expect Medicare to enforce a deadline for all OTP providers to become OTP Medicare certified. If you are not Medicare Certified after this date you will no longer be able to provide OTP services to Dual eligible members. Your organization will only be able to provide services per your State’s Medicaid plan.

My Organization is SAMHSA certified what do we do next?

SAMHSA certified providers are one step ahead in the process to become Medicare Certified. Your MAC must verify SAMHSA certification before accepting the Medicare Certification application.   Refer to the OTP Medicare Enrollment Fact sheet for more information on your next steps. https://www.cms.gov/files/document/otp-medicare-enrollment-fact-sheet.pdf

Does my organization need to notify Aetna when our organization receives our OTP Medicare Certification?

No, Aetna Better Health of ohio will monitor the CMS site and will update providers records in our systems to allow for Medicare OTP reimbursement. It may take up to 30 days from the time your organization appears on the certification list. It is important to submit all claims on or after your OTP Medicare certification effective date under the Medicare OTP codes.

My organization provides OTP for Dual eligible members and Medicaid only members. How do we bill for these services?

This change for 1/1/2020 is for Dual Eligible members. Follow the instructions above for dual eligible members. State Medicaid Agencies will still cover OTP services for Medicaid Only services. Each State Medicaid Agency is unique. You should continue to follow the billing practices outlined in your state for Medicaid OTP services for any Medicaid only members you serve.

 

My organization has existing authorizations for members for OTP services. Do I need to secure a new authorization?

All OTP services require Prior authorization. You do not need to request a new authorization for OTP services for any current member you are presently providing OTP services. The existing authorization will be utilized for your continued services. Once your current authorization expires you will need to request a new authorization. The new authorization you request should reflect the way you are billing which is based upon your OTP Medicare Certification status. For example, if you are not yet OTP Medicare Certified you should not request an auth for OTP services using the new G Codes. If you are OTP Medicare Certified your Prior authorization request should be for the correct Medicare G codes. Once you become OTP Medicare Certified all future prior authorizations will be for the new g codes, Aetna will not issue any authorizations for Medicaid OTP codes for dual eligible after 1/1/20.  

 

 

Provider Notice 01/06/2020 - Payment Delays on New Outpatient Hospital Coverage Claims

 

Dear Hospital Providers,

 

This is a notification letting you know there is a delay in the implementation of the new Outpatient Hospital Coverage Rates that went into effect on 01/01/2020.  This is a result of the delay in publication of CMS’s Integrated OCE Quarterly Release Files and software causing further delay to the 3M Grouper.  

 

To insure against inaccurate payment processing, Aetna has decided to hold all effected EAPG claims until payments may be made with the correct 01/01/2020 rates.  Expected time for system update is mid-February.  If you have any questions for Aetna Better Health® of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

Aetna Better Health® of Ohio

Provider Services

 

Provider Notice PN200106-001

Dear Provider,

 

Effective 02/03/2020, Aetna Better Health of Ohio will change the way HCPCS Code J3145

Injection, testosterone undecanoate, 1 mg (Aveed®) is reviewed and paid, requiring prior

authorization and documented trial and failure of two preferred agents in addition to meeting

clinical criteria in order to be considered for coverage.

 

As always, don't hesitate to contact your Aetna Better Health of Ohio Provider Relations

Representative with any questions or comments at 1-855-364-0974.

 

Thanks for all you do!

 

Sincerely,

 

Aetna Better Health of Ohio

Provider Services

                                                                                                                                                                                                                          Provider Notice PN191221-001

 

Provider Notice 12/13/2019 – N767 Claim Denial

 

Dear Providers,

 

Aetna has recently identified claims that denied in error which impacted all specialty types. Providers that were impacted would have receive this denial reason on their claims’ remittance between the dates of 11/26/2019 to 12/14/2019.

 

N767 – The Medicaid State Requires Provider to be enrolled in the members Medicaid State Program prior to any claim benefits being processed on their claim remittance.

 

If you have identified this type of denial, no action is needed. Aetna has identified all effected claims and is working very quickly to have claims reprocessed.     

 

If you have any questions for Aetna Better Health of Ohio regarding this issue, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

Aetna Better Health of Ohio

Provider Services

 

Provider Notice PN191216-001

Provider Notice 11/13/2019 – PDGM Changes

 

Dear Home Health Provider,

Aetna Better Health of Ohio wanted to provide your organization with an FAQ related to upcoming Medicare changes related to the new Patient-Driven Groupings Model (PDGM). Please share this with staff and billers for your organization. We hope this will assist you when billing Aetna for Home Health claims. 

Frequently Asked Questions

  • Does Aetna have plans to adopt the Patient Driven Groupings Model (PDGM) per Medicare Part A billing requirements?
  • Yes. Aetna will implement the PDGM payment model for Skilled Home Health Medicare Part A billing.
  • Does Aetna plan to change the existing claim billing requirements to accommodate the new PDGM components such as the submission of a PDGM HIPPS Code and/or other information on Medicare claims?
  • Providers should bill using Medicare guidelines. Aetna will use a pricing tool (Burgess) for calculating claim payments that is consistent with Medicare Fee For Service. The payment changes will be reflected in claims with Dates of Service (DOS) on or after the effective date of PDGM being implemented in our system. Aetna will follow all contractual arrangements and negotiated arrangements regarding reimbursement. Most provider contracts are 100% Medicare allowable.
  • When does Aetna plan to implement PDGM requirements and/or changes?
  • Our changes will align with Medicare effective date which would be 1/1/20 Dates of Service (DOS) forward.

Additional information can be found related to the PDGM Medicare changes at the following sites:

Should you have any questions related to this communication, please contact our Provider Experience department at 1-855-364-0974.

Sincerely,

Aetna Better Health of Ohio

Provider Experience

Provider Notice PN191113-001

Provider Notice 10/30/2019 - Secondary Medicaid Payment Responsibility in Coordination of Benefits (COB) Situations

 

Dear Provider,

 

Aetna Better Health is committed to ensuring that the claims you submit are processed in a timely and accurate manner. Aetna Better Health serves as a Medicaid managed-care organization (MCO) on behalf of the State of Ohio and arranges for the provision of covered services to its members. When more than one program or payer has payment responsibility for a particular service rendered to a member—for example, when a service is covered under both Medicare and Medicaid—Aetna Better Health follows applicable coordination-of-benefits (COB) principles to determine which program/payer has primary payment responsibility (PPR) for that service. This COB analysis includes a determination of the amount payable by the program/payer having PPR, along with the amounts, if any, payable by programs/payers that have secondary or lower payment responsibility. If a service is covered under both Medicaid and another program/payer, Medicaid never has PPR.

 

Under established COB principles, if the amount of the payment made by the program/payer having PPR (e.g., Medicare) exceeds the amount that the secondary program/payer (e.g., Medicaid) would have paid if it had PPR, then the secondary program/payer has no payment responsibility.

 

Aetna Better Health has identified an error in the COB method with outpatient claims by which it calculated the Medicaid amount that is secondarily payable when Medicare has PPR for a particular service. Specifically, Aetna Better Health erroneously made certain secondary payments to providers when, under the COB principle described above, the Medicaid amount that was secondarily payable should have been zero.

 

Please be advised, going forward Aetna Better Health will apply the above-described COB principle strictly and consistently. As a result, the aggregate amount that providers receive from Aetna Better Health for certain services may decrease now that the secondarily payable Medicaid amounts on those services will be zeroed out appropriately. Aetna Better Health will be reprocessing outpatient claims with a date of service on or after 08/02/2018 and apply this correct COB principle.

 

Thank you for your participation. We look forward to continuing a successful working relationship. If you have further questions about the information in this notice, please contact your Network Account Manager or Provider Services at 1-855-364-0974.

 

Sincerely.

 

Aetna Better Health of Ohio

Provider Services

Provider Notice PN191030-001

Provider Notice 09/03/2019- S5121 and S5135 modifier edit

 

Dear Waiver Providers,

 

This is a notification of a recent Ohio Department of Medicaid billing change that is affecting certain waiver providers.   Beginning 7/01/2019, providers that are billing service codes S5121 (OH Home Maintenance and Chore) or S5135 (OH Community Integration) should not use a modifier. If a provider submits a claim for either of these codes with a modifier the claim will deny and the provider will need to rebill with a corrected claim.

 

If you have any questions for Aetna Better Health of Ohio regarding this update, please contact Provider Services at 1-855-364-0974.

 

Sincerely,

Aetna Better Health of Ohio

Provider Services

Provider Notice PN190903-001

Provider Notice 08/28/2019- Patient-Driven Payment Model (PDPM)

 

Dear Skilled Nursing Facility,

 

Aetna Better Health of Ohio wanted to provide your organization with an FAQ related to upcoming Medicare changes related to the new Patient-Driven Payment Model (PDPM). Please share this with staff and billers for your organization.  We hope this will assist you when billing Aetna for SNF claims.

 

Frequently Asked Questions:

  • Does Aetna have plans to adopt Medicare’s PDPM payment model?
  • Yes. Aetna will implement the PDPM payment model for SNF claims.
  • Does Aetna plan to change the existing claim billing requirements to accommodate the new PDPM?
  • Providers should bill using Medicare guidelines. Aetna will use a pricing tool (Burgess) for calculating claim payments that is consistent with Medicare Fee For Service (FFS). The payment changes will be reflected in claims with Dates of Service (DOS) on or after the effective date of PDPM being implemented in our system.  Aetna will follow all contractual arrangements and negotiated arrangements regarding reimbursement. Most provider contracts are 100% Medicare allowable.
  • When does Aetna plan to implement PDPM requirements and/or changes?
  • Our changes will align with the Medicare effective date which is any claim with a Date of Service (DOS) 10/1/19 forward.

 

Additional information can be found related to the PDPM Medicare changes at the following sites:

 

Should you have any questions related to this communication, please contact our Provider Experience department at 1-855-364-0974.

 

Sincerely,

Aetna Better Health of Ohio

Provider Experience Team

 

Provider Notice PN190828-001

Provider Notice 8/23/2019 – SNF Rates

 

Dear Skilled Nursing Facility providers,

 

At the beginning of the fiscal year, Ohio Department of Medicaid (ODM) provided all managed care plans with the skilled nursing facility (SNF) rates beginning on July 1, 2019. Due to the delay in the passage of the state budget, ODM requested that no SNF rates payments be made until the state budget was passed and the appropriate rate of payment could be established for the delay period.  Since the budget has now passed, Aetna will proceed with paying SNF for services provided beginning July 1, 2019 with the June 30, 2019 rates for the period of July 1, 2019 through and including July 17, 2019.  ODM has supplied updates rates for the period of July 18 forward. 

 

Claims with DOS 7/1/2019 – 7/17/2019 (will pay June 30th rate) and DOS 7/18/2019 – 7/31/2019 (will pay new rate).

 

Provider Actions

Due to the rate change in the middle of the month providers will need to split dates of services on separate claim lines. If you have already submitted a claim with all dates of service on one line you will need to submit a corrected claim.

Example of billing for DOS 7/01/2019 – 7/31/2019

Claim Line 1 DOS 7/01/2019 - 7/17/2019

Claim Line 2 DOS 7/18/2019 - 7/31/2019

 

If you have any questions for Aetna Better Health of Ohio regarding this update, please contact Provider Services at 1-855-364-0974.

 

Sincerely, 

 

Aetna Better Health of Ohio

Provider Services

Provider Notice PN190823-001

Provider Notice 7/31/19- 340B Drug Program

 

Dear Provider,

 

Beginning January 1, 2018, Medicare pays an adjusted amount of the average sales price (ASP) minus 22.5% for certain separately payable drugs or biologicals that are acquired through the 340B Drug Program and are furnished to a Medicare beneficiary by a hospital paid under the OPPS(Outpatient Prospective Payment System)  that is not excepted from the payment adjustment policy. For purposes of this policy, “acquired through the 340B Drug Program” means that the drug was purchased at or below the 340B ceiling price from the manufacturer and includes 340B drugs purchased through the Prime Vendor Program. Medicare will continue to pay for separately payable drugs that were not acquired through the 340B Drug Program and furnished by a hospital paid under the OPPS at ASP plus 6%.

 

Aetna Better Health of Ohio has determined that our configuration for Medicare Part B 340B drug reimbursement has not been properly reducing payment by 22.5% for outpatient drugs. If you are a 340B covered entity and part of the Prime Vendor Program, it is expected that your claims for 340B drugs purchased through the program should include either the JG or TB modifier. When the JG modifier is appended, the 22.5% reduction will occur. If the TB modifier is present, no reduction in payment will occur.

 

Aetna Better Health of ­­Ohio is taking steps to configure its system to align with Medicare’s requirement. We will be recouping and correcting overpaid claims dating back one year from DOS July 1, 2018, to present. As we work on the configuration, which includes a 3-step validation (provider is 340B covered, the drug is a 340B drug, and the JG modifier is present) before reducing the payment, we are exploring the timeline for the recoupment with our claims department. We expect the recoupment to occur in the next 30 to 45 days.

 

For more information regarding the 340B Drug Program, please visit the following sites or contact Provider Services team at 1-855-364-0974 or send an email to OH_ProviderServices@aetna.com.

 

For more information, please visit:

If you are not a 340B covered entity participating in the Prime Vendor Program with HRSA, this memo does not apply to you at this time.

 

Sincerely,

Aetna Better Health of Ohio

Provider Notice PN190731-001

Provider Notice 07/17/2019 - New Updates on Clinical, Payment and Coding Policies 

 

Dear Provider,

 

A review of processes has been completed and changes will be updated to the current clinical, payment and coding policy positions. The attached documentation will provide additional information.   

Please feel free to reach out to Provider Services at 1-855-364-0974, if there are additional questions.

 

Sincerely,

Aetna Better Health of Ohio

 

Provider Notification PN190717-001

Provider Notice 06/13/2019 - Provider Check Delays

 

Dear Provider,

Due to a system error, we are notifying you that Aetna Better Health of Ohio’s check run that is normally scheduled to happen each Saturday will not occur this week as planned.  Our Saturday June 15th check run will be delayed and will now occur on Tuesday June 18th. We do not anticipate any future check run delays related to this issue.

We apologize for the delay and any inconvenience this issue may have caused.  However, the delay is being done in an effort to ensure provider’s checks are received for the correct amounts.  If you have any questions, please do not hesitate to reach out to our Provider Services department by calling 1-855-364-0974. 

We appreciate your understanding, and for your service to our members. 

 

Sincerely,

Aetna Better Health® of Ohio

Provider Experience

 

Provider Notification PN190613-001

Provider Notice 6/11/2019- Electronic Visit Verification (EVV) training

 

Phase 2 of EVV is fast approaching and important EVV training information can be accessed here.  

 

Provider Notification PN190611-001

Provider Notice 5/31/2019- Incontinence Supply Codes

 

May 31st, 2019

 

Dear Provider, 

 

Effective September 1, 2019, Aetna Better Health of Ohio will not require prior authorization for the following CPT/HCPCS code before services are rendered. 

Please note the allowable units for each service below.

 

CODE

DECRIPTION

ALLOWABLE UNITS

T4545

Incontinence product, disposable, penile wrap, each

200 / Month

 

 

Should you have any questions related to this change in PA, please don't hesitate to contact our Provider Experience team at  1-855-364-0974. 

Thank you for your continued dedication to our members!

 

Sincerely,

Provider Experience

Aetna Better Health of Ohio

 

Provider Notification PN190531-001

Provider Notice 05/07/2019 Hospice Providers

 

Dear Hospice & Skilled Nursing Facility providers,

 

Recently, the Ohio Department of Medicaid (ODM) provided clarification to Managed Care Organizations related to Hospice providers billing for Skilled Nursing Facility (SNF) Room & Board.

Per the Center for Medicare and Medicaid Services (CMS) regulations, when an individual resides in a SNF and is receiving hospice services, the hospice provider must bill the managed care plan for room and board.

CMS has indicated that room and board payment needs to go to the hospice provider (and not the skilled nursing facility) because they are considered the provider of record per SSA 1905(o)(3)(C). Furthermore, 1902(a)(32) and 42 CFR 447.10 prohibits provider payment reassignment.

 

Per this guidance and regulation, beginning with dates of service July 1, 2019 or after, Aetna Better Health of Ohio (a MyCare plan) will only accept billing from Hospice providers for room and board services when an individual is receiving hospice services and resides in a skilled nursing facility.

 

Hospice provider must:

 

Note: Hospice Providers DO NOT need to obtain an authorization

 

SNF provider must:

  • Continue to bill for R&B for members in Hospice for dates of service thru 6/30/19 on UB04
  • No longer bill rev code 0658 for DOS on or after 7/1/19

 

Please Note: Aetna Better Health of Ohio will NOT be contracting with Hospice providers since Hospice services are carved out of MyCare, but will pay Hospice providers as non-PAR for claims for SNF Room & Board services.  Please refer to our provider manual for information about timely filing, claim submission, and resources available to you as a non-PAR provider.

 

Beginning with dates of services July 1, 2019 or after, Aetna will deny any skilled nursing facility claims for room and board that are billed directly by the skilled nursing facilities for individuals receiving hospice. SNFs should work with their partner Hospice providers accordingly for reimbursement if applicable.

 

Ventilator Dependent Members:

In the rare instance that a member who is ventilator dependent or ventilator weaning, the SNF is reimbursed at the ventilator enhanced rate. Hospice providers shall work with the SNF to identify the SNF’s ventilator status with ODM for submitting ventilator room and board claims. Hospice providers should submit the proper U1, U2, U3, or U4 modifier for their claims per the chart below:

Description of service Specialty code RCC DX Code Modifier Rate
Vent dependent- full rate for meeting VAP threshold 862 419 Z99.11 U1 $819.49
Vent dependent rate 5% reduction for not meeting VAP threshold 864 419 Z99.11 U2 $778.52
Vent  weaning- full rate for meeting VAP threshold 867 410 Z99.11 U3 $983.39
Vent weaning -5% reduction for not meeting VAP threshold 868 410 Z99.11 U4 $934.22

 

Members with a Patient Liability:

When applicable, Aetna Better Health is required to deduct Patient liability for SNF member’s Room and Board claims.  Effective 7/1/19, Aetna Better Health will begin reimbursing the Hospice provider for room and board,  as well as deduct the full  member’s patient liability from the Hospice provider’s claim  according to  the member’s eligibility file from ODM where patient liability is reported. If the Patient Liability exceeds the total on the claim, the remaining balance of patient liability will be deducted off any hospice claims submitted for that member during the same month based upon the date of service.  It is still the SNF’s responsibility to collect the member’s patient liability, so Hospice providers will need to coordinate with SNFs related to Patient Liability accordingly.

 

If you have any questions for Aetna Better Health of Ohio regarding this update, please contact Provider Services at 1-855-364-0974.

 

Sincerely, 

 

Aetna Better Health of Ohio

Provider Services

Provider Notification PN190507-001

 

Provider Notice 04/11/2019 Ambulance Providers

 

Aetna Better Health of Ohio identified an issue that was causing certain claims deny inappropriately. Click here for additional information regarding the dates and codes affected. 

 

                                                                                                                                                                                                   Provider Notification PN190411-001

Provider Notice 03/26/2019 Behavioral Health claims

 

Dear Behavioral Health Provider,

 

Some Behavioral Health claims containing codes which are payable only under the Medicaid line of business did not bypass Medicare properly in our system, resulting in incorrect payments, primarily a short payment. The codes included in this error were:

 

90785, 90791,90832, 90834, 90837, 90839, 90840, 90846, 90847, 90853, 96101, 99354, 99355, G0396, G0397, H0006, H0036, H2017, H2019.

 

We identified claims that were affected starting on 7/1/18 through 3/19/19. Aetna is currently in process of having all effected claims reprocessed and expects the project to complete in mid-April.  If you do not see a correction to your claim and feel the payment was underpaid, please reach out to either your Provider Relations Liaison or our Provider Services team at OH_ProviderServices@aetna.com.

 

We apologize for any inconvenience this error may have caused and thank you for your continued service to our members.

 

Sincerely,

Provider Services

Aetna Better Health® of Ohio

 

Provider Notification PN190326-001

 

Provider Notice 03/26/2019 Behavioral Health claims with specialty providers

 

Dear Behavioral Health Provider,

 

Recently, Aetna Better Health of Ohio identified an issue that effected payment on 4 separate Behavioral Health codes:

 

H0006, H0036, H2017, H2019

 

Claims containing these codes did not price correctly based on the provider specialty being billed on the claim, resulting in a zero-dollar payment. This issue effected claims starting with Dates of Service starting 1/1/19, and our system was corrected for any claims received after 3/19/19.

 

All effected claims are currently being reprocessed to pay the correct rate and will be completed by mid-April. If you do not see a correction to your claim and feel the payment was underpaid, please reach out to either your Provider Relations Liaison or our Provider Services team at OH_ProviderServices@aetna.com .

 

We apologize for any inconvenience this error may have caused and thank you for your continued service to our members.

 

Sincerely,

Provider Services

Aetna Better Health® of Ohio

 

Provider Notification PN190326-002

Provider Notice 03/26/2019 Denials on claims for billing codes requiring no authorization

 

Dear Provider,

 

Aetna Better Health of Ohio previously communicated prior to the beginning of the year a list of codes that would no longer require authorization starting 1/1/19.

 

These changes were put in place for the codes listed on that communication, however, on 3/12/19, a system issue switched these codes back to ‘authorization required’ status causing denials in error. We identified this issue quickly and have put mechanisms in place to prevent these claims from denying for no authorization starting 3/20/19.

 

All effected claims are currently being reprocessed to pay the correct rate and will be completed by mid-April. If you do not see a correction to your claim and feel the payment was underpaid, please reach out to either your Provider Relations Liaison or our Provider Services team at OH_ProviderServices@aetna.com .

 

We apologize for any inconvenience this error may have caused and thank you for your continued service to our members.

 

Sincerely,

Provider Services

Aetna Better Health® of Ohio

 

Provider Notification PN190326-003

Provider Notice 03/13/2019 Claims for Behavioral Health, Durable Medical Equipment and Home Health Agency providers

 

Dear Provider,

On February 27th, Aetna identified an issue that effected claims for Behavioral Health, Durable Medical Equipment and Home Health Agency providers.  Claims affected from the issue span adjudication dates of 2/6/19 thru 3/1/19.

 

Only claims for Opt-Out members were affected. Certain codes which are Medicaid only covered services were denying incorrectly for no EOB (Remit Edit 377). Aetna Better Health of Ohio has already reprocessed and paid majority of claims affected, and anticipate all claims affected to be reprocessed no later than 4/15.

 

If you have any claims that meet the criteria above that have not been reprocessed and paid after 4/15, please reach out to Provider Services at 1-855-364-0974 or contact your Provider Relations Liaison for further assistance.

 

We apologize for the issue, and are working to resolve it as quickly as possible.

 

Thank you for your continued service to our members.

 

Sincerely,

Provider Services

Aetna Better Health® of Ohio

 

Provider Notification PN190313-001

 

Provider Notice 01/28/2019 Assisted Living billing codes for Skilled Nursing Facilities (SNF)

 

Ohio Department of Medicaid (ODM) confirmed for Aetna Better Health of Ohio that Assisted Living claims must be billed using a unique Medicaid ID that is authorized for Assisted Living specifically. The attached information will provide additional details for the correct billing codes. 

 

 

                                                                                                                                                                                                   Provider Notification PN190128-001

Provider Notice 01/17/2019 Electronic Visit Verification Communication

 

Aetna Better Health of Ohio would like to share provider-related information for the Electronic Visit Verification program. Click here to see the latest information from the Ohio Department of Medicaid. 

 

                                                                                                                                                                                                                                                     Provider Notification PN190117-001

Provider Notice 11/27/2018 - Waiver Service Authorization Attestation

Effective January 1, 2019, Aetna Better Health of Ohio will be requiring attestations from certain waiver providers for authorized services. Click here to see a list of provider types effected.

 

Provider Notification PN181127-001

Provider Notice 12/21/2018 Utilization Management FAQ’s for Providers

 

Aetna Better Health of Ohio has made a change to the pre-denial communication. Click here to see a list of FAQ’s for Utilization Management.

 

                                                                                                                                                           Provider Notification PN181221-001

Provider Notice 11/20/2018 - Pre-Denial Process for Urgent Authorization Requests

 

Aetna Better Health of Ohio has made a change to the pre-denial process for urgent requests. Click here for additional information. 

                             

                                                                                                                                                                                                      Provider Notification PN181120-002

 

Provider Notice 11/20/2018 - Changes in Prior Authorization Requirements

Effective January 1, 2019, there will be changes in Aetna Better Health of Ohio's prior authorization requirements. Click here to see a full list of Home Healthcare CPT codes that will be effected.

 

Provider Notification PN181120-001

Provider Notice 11/15/2018 - Medicaid Claim Rework Project

Dear Providers,

 

Aetna Better Health of Ohio wanted to notify you that, in a recent claims projects where there was a Medicare and Medicaid eligible payment, some claims projects only reprocessed the Medicare claim and not the Medicaid claim, leaving the provider with a new Medicare payment, but the original Medicaid payment. 

 

We are in the process of having the Medicaid claims associated with this issue reversed and reprocessed against the new Medicare claim associated with those projects. You may notice some Medicaid claim reversals and repayments as a result on future remits.  The reversal and corresponding reprocessed Medicaid claim may not appear on the same remit, but will be done in close proximity.

 

Some of the new Medicaid claims may result in a net recoupment, while others in a net payment. We do not anticipate a significant net difference in payment since the primary payment has been made, and the original Medicaid payment was not reversed during the original projects. We anticipate all of the claims effected to be reprocessed and a new Medicaid payment adjudicated in our system by 12/7/18.   

 

PLEASE NOTE: This would not affect any claim that is only eligible for Medicaid payment.   Should you have any questions, please contact Provider Services at 1-855-364-0974.

 

We appreciate your business.

 

Sincerely,

Provider Services

Aetna Better Health of Ohio

Provider Notification PN181115-001

Provider Notice 11/09/2018 - Ambulatory Surgery Center (ASC) and Acute Hospital EAPG Billing

Aetna Better Health of Ohio would like to clarify that Ambulatory Surgery Centers may not submit claims on a UB04 form using bill type 83X. Click here to read more.

Provider Notification PN181109-001

Provider Notice 9/28/2018 - Updates to Evaluation & Management (E&M) Code Billing

Aetna Better Health of Ohio continues its commitment to correct coding and the implementation of programs that support nationally recognized and accepted coding policies and practices. Evaluation and Management (E&M) coding is an area that the Centers for Medicare & Medicaid Services (CMS) has identified as having significant error rates. Click here to read more.

Provider Notification PN180928-001

Provider Notice 9/12/2018 - Invalid Diagnosis Codes

Aetna Better Health of Ohio recently identified an issue where our claims encounter data was rejecting due to invalid diagnosis codes. Click here to read more.

Provider Notification PN180912-001

Provider Notice 7/30/2018

For your convenience we are redistributing a communication from the Ohio Department of Medicaid regarding the Electronic Visit Verification (EVV) system. Click here to read the full notice.

Provider Notification PN180730-001

Provider Notice 7/25/2018

Effective August 25, 2018 Aetna Better Health of Ohio, for all lines of business, will require prior authorization for certain CPT/HCPCS codes before services are rendered. Read our full notice here.

Provider Notification PN180725-001

Provider Notice 7/3/2018

Effective 10/1/2018 codes not priced on the Aetna Market Fee Schedule will reimburse at 20% of billed charges. Click here to read more.

Provider Notification PN180703-001

Provider Notice 6/8/2018

Skilled Nursing Facility-Direct Schedule with Preferred Transportation Provider.

Provider Notification PN180608-002

Provider Notice 6/8/2018

Outpatient hospital covered services effective July 1, 2018 and August 1, 2018.

Provider Notification PN180608-001

Provider Notice 5/16/2018

Click here to learn about an important update to our policies regarding drug testing.

Provider Notification PN180516-001

Provider Notice 1/25/2018

Click here to learn about Aetna Better Health of Ohio's effort to help close the gap on health disparities for African-Americans who have hypertension.

Provider Notification PN180125-001

Provider Notice 1/22/2018

Effective March 1, 2018 there will be changes in Aetna Better Health of Ohio's prior authorization requirements. Click here to see a full list of CPT codes that will be effected.

Provider Notification PN180122-001

Provider Notice 12/21/2017

Aetna Better Health of Ohio, with our partnership with CMS and Medicaid, continues to address medical cost savings initiatives where appropriate. To stay current with the national coding standards, we are updating our current modifier discount tables to align with those national guidelines. Click here to read the full communication.

Provider Notification PN171221-001

Provider Notice 11/08/2017

the State of Ohio released a revision to several OAC rules pertaining to hospitals. Read this notice to see which rules have been updated.

Provider Notification PN171108-001

Provider Notice 11/02/2017

OhioMHAS will be holding DEA DATA 2000 waiver trainings for physicians, third year resident physicians, physician assistants and nurse practitioners across Ohio. Click here to read more and sign up for one of these trainings.

Provider Notification PN171102-001

Provider Notice 09/25/2017

Help us to ensure that our provider directory is up to date and take this short survey. Your office will also have an opportunity to complete cultural competency accreditation within the survey if you have not already done so.

Click Here to read more

Provider Notification PN170925-001

Provider Notice 09/22/2017

We have updated our dates and times for on-site and online training resources for behavioral health redesign.

Click Here to read more

Provider Notification PN170922-001

Provider Notice 09/14/2017

Our Quality Navigator Team will be hosting two new webinars. You can find out more, and register for one of these webinars by clicking the link below

Click Here to read more

Provider Notification PN170914-001

Provider Notice 09/12/2017

CMS has provided clarification on the guidance for coverage of skilled services in accordance with Jimmo v. Sebelius. Plese click the link below to learn more.

Click Here to read more

Provider Notification PN170912-001

Provider Notice 08/29/2017

In an effort to help ensure your organization and Aetna Better Health of Ohio are prepared for the upcoming Behavioral Health Redesign changes that take effect with the Ohio Department of Medicaid starting on January 1st, 2018 we would like to encourage your organization to participate in a 'claims testing' period.

Click Here to read more

Provider Notification PN170829-001

Provider Notice 07/20/2017

Aetna Better Health of Ohio would like to inform our behavioral health facilities that Medicaid Managed Care Plans may cover IMD services effective 7/1/2017

Click Here to read more

Provider Notification PN170720-001

Provider Notice 05/24/2017

Aetna Better Health of Ohio regularly reviews and analyzes claim handling practices to identify opportunities for improvement. To that end, we are pleased to announce that as of May 31, 2017, we are working with Cotiviti Healthcare (Cotiviti) to assist us with provider claim reviews and reimbursement review practices.

Click Here to read more

Provider Notification PN170524-001

Provider Notice 04/11/2017

Developed by the Centers for Medicare & Medicaid (CMS), the Medicare Outpatient Observation Notice (MOON) serves as the standardized notice used by hospitals and critical access hospital (CAH) to notify Medicare patients who receive more than 24 hours of observation services that their hospital stay is outpatient, not inpatient. You must provide the MOON to these patients no later than 36 hours after services begin.

Click Here to read more

Provider Notification PN170411-001

Provider Notice 04/10/2017

Effective 05/30/2017 Aetna will have the capability to look across claim types and resolve conflicts that may exist between professional and institutional claims.

Click Here to read more

Provider Notification PN170410-001

Provider Notice 04/07/2017

Effective 05/01/2017 Aetna Better Health of Ohio will change the way unlisted and non-specific CPT and HCPCS codes are reviewed and paid.

Click Here to read more

Provider Notification PN170407-001

Provider Notice 01/25/2017

To all participating Skilled Nursing Facilities; Aetna Better Health of Ohio's partnership with Advance Health began on 01/01/2017. If you are interested in attending one of our webinars to familiarize yourself with Advance Health please read this notification and register for one of the trainings today.

Click Here to read

Provider Notification PN170125-001

Provider Notice 12/19/2016

Read this important reminder regarding billing practices.

Provider Notification PN161219-001

Provider Notice 11/02/2016

To Skilled Nursing Facilities: Aetna Better Health of Ohio will be ending its relationship with Optum on 12/31/2016.

Read more.

 Provider Notification PN161102-001

Provider Notice 09/29/2016

Effective 09/29/2016 the Ohio Department of Medicaid will retire procedure code G0154.

Read more.

 Provider Notification PN160929-001

Provider Notice 09/02/2016

Effective 09/26/2016 Aetna Better Health of Ohio members will require prior authorization for Radiology, Cardiology & Pain Management services from eviCore healthcare for dates of service 10/03/2016 and after.

Read more.

Provider Notification PN160902-001

Provider Notice 08/24/2016

Aetna Better Health of Ohio is pleased to release their Home and Community-Based Services Waiver Program Overview Guide. This document is designed to concisely lay out the Waiver Service process, waiver services, and general information about the program.

Read the guide.

Provider Notification PN160824-001

Provider Notice 05/05/2016

All providers who prescribe Part D drugs must be enrolled in Medicare or have validly opted-out of Medicare by February 1st, 2017 in order to continue prescribing Part D drugs to your patients.

Click on one of the links below for full details:

Providers

Pharmacists.

Provider Notification PN160505-001

Provider Notice 03/24/2016

Keeping Your Medicare Advantage Directory Information Up to Date - Aetna Better Health of Ohio contacts you quarterly to ensure that your information in our provider directory is accurate. There's an easier way to make all of your office/facility directory information available to each health plan that your organization participates with using CAQH.

Click Here to learn more.

Provider Notification PN160324-001

Provider Notice 03/18/2016

Important changes have been made to the Aetna Better Health of Ohio Prior Authorization List. Click the link below to read the details.

Prior Authorization Changes - March 2016

Provider Notification PN160318-001

Provider Notice 03/01/2016

If you are a Medicaid-participating provider and have received a Revalidation Notice from the Ohio Department of Medicaid, it means you are approaching the End Date of your Medicaid Provider Agreement.

Click here to read more about ODM’s revalidation process.

IMPORTANT: Failing to respond to ODM’s revalidation request before the Medicaid Agreement End Date could result in termination of the Agreement, and your claims will not be eligible for payment.

Provider Notification P160301-001

Provider Notice 01/12/2016

Aetna Better Health of Ohio has released a chart detailing our standards and timeframes for appointments with our members.

To view the chart, please click here.

Provider Notification PN160112-001

Providers: Not enrolled or properly opted-out of Original Medicare?

Please click the link below to read this important communication from the Centers for Medicare & Medicaid Services if you are a provider who prescribes drugs for Medicare patients and have not enrolled in or properly opted-out of Medicare.

Click Here

Provider Notification PN151016-001

Claims Payment Systemic Errors (CPSEs)

This section contains a report of all current and closed system issues identified by Aetna Better Health of Ohio (ABHO) which have resulted in claims payment errors.

Important notes regarding this report:

  • The issues are listed from newest to oldest from when they were identified (i.e. newest identified will be nearest the top)
  • Each issue contains a summary and an expected resolution date. 
  • The report is updated monthly. 

If you have any questions or concerns, please reach out to your provider liaison, or contact Provider Services at 1-855-364-0974.

CPSE Report

Coming Soon.

Aetna Better Health of Ohio Behavioral Health Redesign Overview Video

Behavioral Health providers can locate the latest updates to the BH Redesign codes, rates and rules on Ohio's official Behavioral Health Redesign page by clicking here.

OAHP Regional Forums Dates and Times

 

Communications