Together, we can improve health care quality
At Aetna Better Health of Pennsylvania, we value our provider partners. We want to make it easy for you to care for our members and guide them down the path to better health.
Please start by reading our provider manual. If you aren’t yet a contracted provider, learn more about joining our network. We also have information about clinical practices, all of the forms and resources you need, as well as the latest provider news and notices.
Our network providers and other health care providers are our partners in the delivery of high-quality health care services to our members. Good communication is the key to this successful partnership. Please take a minute to review our Medicaid quick reference guide.
Provider Relations Representatives
We're here to help.
You can contact your provider relations representative to help with your health plan needs. He or she can schedule a visit to answer questions about:
- health plan initiatives like pay-for-performance
- web portal navigation
- and more!
Contact our provider relations department at 1-866-638-1232 for more information.
Please read: Important provider revalidation message from the Department of Human Services
On September 25, 2016, the Department of Human Services (DHS) dis-enrolled multiple provider service locations from the Medical Assistance Fee-For-Service (FFS) Program. Beginning September 26th, these FFS service locations cannot bill for services provided.
If you have a FFS claim(s) denied or don’t receive payment for a FFS claim submitted after September 25, 2016 and did not revalidate and you enrolled in the Medical Assistance program prior to September 25, 2011, you may have been dis-enrolled, per Medical Assistance Bulletin 99-16-06.
All service locations enrolled in the MA program must revalidate including group enrollments as noted in DHS Provider Quick Tips #198.
To re-enroll please submit a revalidation application (re-activation application if you are submitting via the Electronic Provider Enrollment Portal) as soon as possible.
The effective date of your re-enrollment will be when DHS has received your complete revalidation/re-activation application.
A successfully completed application will have the following items:
- Ownership and controlling interest section completed
- Signed application
- Include all attachments
If you received a returned application from DHS, one or more of the above items were not complete.
Once providers have been re-enrolled they may submit FFS claims for services provided as of the effective date of the enrollment. Please review this FAQ provided by DHS for additional information.
How does this impact you as a managed care organization (MCO) provider?
You will not be dis-enrolled from the Aetna Better Health network at this time. DHS is temporarily suspending the enforcement of the revalidation requirements for providers that participate in managed care that have not yet completed the revalidation process.
This temporary suspension applies only to current MCO network providers that have not completed the revalidation process. Providers that enroll in the Medical Assistance Program for the first time must be validated before being accepted in the MCO network.
Attention PCPs - Enroll in TiPS for your pediatric patients
TiPS (Telephonic Psychiatric Consultation Service Program) for Primary Care Providers
TiPS is a new Pennsylvania HealthChoices program designed to increase the availability of child psychiatry consultation teams regionally and telephonically to primary care providers (PCPs) and other prescribers of psychotropic medications, for children insured by Pennsylvania’s Medical Assistance (Medicaid) Program. The program provides real time peer to peer resources to the PCP who desire immediate consultative advice for children (up to age 21) with behavioral health concerns.
TiPS provides one team per each HealthChoices zone, and ensures both access to quality services in the appropriate setting based on need, and mitigates the lack of available child psychiatry resources.
Learn more about this innovative psychiatry consultation program and how you can enroll here.
Provider Revalidation Need-to-Know Information
The deadline is rapidly approaching for Medical Assistance provider enrollment/revalidation.
The Pennsylvania Department of Human Services (DHS) requires providers to revalidate their PROMISe ID and service locations by July 30, 2016.
Please be aware that if you are not enrolled or not submitted a revalidation application by July 30, 2016:
- You will not receive payments from the Medical Assistance Fee-For-Service (FFS) Program beginning September 25, 2016
- Payments cannot be made retroactively
Click here to check the status of your application or apply online today.
Check out this provider revalidation Need-to-Know Guide for additional important information.
SNAP (Food Stamp) Changes
Beginning June 1, 2016 in some areas of PA, able-bodied adults, age 18-49, without children in the household (“ABAWDs”) will lose SNAP benefits as a result of reaching their 3-month time limit unless they meet certain criteria.
It’s important for providers to know they can sign the medical exception form for individuals to keep their SNAP benefits.
Transgender Webinar Series - CEU opportunity
The MidAtlantic AIDS Education and Training Center (MA AETC) will host a no-cost Transgender Webinar Series in March, April and May 2016. These webinars are based upon topics discussed and selected at the HIV Planning Group (HPG) and the MA AETC. CEUs are available as applicable.
You can access webinar topics, dates and registration information by clicking here.
HIPAA 5010 and ICD-10 Information - 10/1/2015
On January 15, 2009 the US Department of Health & Human Services issued two final rules for adoption:
- An updated HIPAA X12 standard version 5010 for electronic transactions, with a compliance date of January 1, 2012. The updated format has more than 1300 changes to the 4010 standard (with 600+ just for claims).
- Adoption of the ICD-10 Code Sets with a compliance date in October 2015 (version 5010 accommodates the ICD-10 code structure; 4010 does not).
Aetna Better Health met the compliance requirements for the federally mandated HIPAA 5010 version transactions for 1/1/2012 and is on track to be able to accept ICD-10-CM & PCS Codes for dates of service for October 2015.
Online ICD-10 Resources
- Road to 10: The Centers for Medicare and Medicaid Services (CMS) has created a website that's a great resource for small physician practices and specialty practices.
- Crosswalks for the Top 50 Codes by Specialty at the AAPC website
- 100 Tips for ICD-10-PCS Coding at icd10monitor.com
- Free code conversion tool from icd10monitor.com
- Quick tips for qualifiers from Pennsylvania's Department of Human Services (DHS)
Pennsylvania Medicaid EHR Incentive Program
The Medicaid Electronic Health Records Incentive Payment Program was created by the American Reinvestment and Recovery Act and administered by Centers for Medicare & Medicaid Services. This program provides funding to states to develop and administer provider incentive programs.
Click here to learn more about Pennsylvania’s Medical Assistance Health Information Technology Initiative.
CHIP benefit changes effective 12/1/2015
On August 20, 2015, Governor Tom Wolf announced that all CHIP health insurance plans would provide enhanced benefits. The added benefits are outlined in the Affordable Care Act. These benefits take effect for all children enrolled in CHIP on December 1, 2015.
- To see Governor Wolf’s announcement, go to http://bit.ly/1JeHA1b
- To access the Pennsylvania Insurance Department’s CHIP website go to http://www.chipcoverspakids.com/
These changes include removing some historical benefit limits on specific services to ensure Minimal Essential Coverage (MEC) compliance for all CHIP Products.
Some categorical benefit changes include:
- Increasing vision services to include low vision items and “add-on” services such as protective coating, when medically necessary.
- Adding sealants to the dental benefit package
- Ensuring parity in the number of behavioral health visits without limit
- Increasing outpatient rehabilitation visit limits to 30 per modality per benefit year (PT, OT, ST)
- Dollar limits for autism services have been removed
- Coverage for a home health visit when discharged from the hospital for a delivery or mastectomy
For a full list of changes, please see the updated CHIP member handbook on our website.
There is nothing current Aetna CHIP members need to do to get these benefits
All Aetna CHIP members will automatically receive these enhanced health benefits. Members will not receive new ID cards as the benefits are now MEC required for all Free, Low and Full Cost CHIP products by all CHIP contractors in the Commonwealth of Pennsylvania.
If Aetna CHIP members have any questions, they can call us at 1-800-822-2447. We’re here Monday to Friday, 8:00 a.m. to 5:00 p.m. TTY users please call 1-800-628-3323.
If you have any questions on these changes please contact Provider Relations at 1-866-638-1232, option 3.
Provider Reports Management Tool
We are pleased to inform you that your Quality Measurement Reports are now available online. You may now access year-to-date reports through the Provider Reports Management Tool on our secure web portal.
Some examples of the types of reports you can access include:
- HEDIS Gaps-in-Care Reports
- Pay-for-Performance Measure Reports
These reports serve as a guide for which Aetna Better Health members need care and where your practice stands regarding Pay-for-Quality incentives for the care you provide.
Be sure you receive credit for the care you provide to Aetna Better Health members
Pay-for-Quality is awarded for care captured administratively through claims submissions.
If you have provided care that we may not have captured due to potential claims or coding issues, please contact Aetna Better Health Provider Relations at 1-866-638-1232, option 3. You can also directly contact the Quality Translator that has been sending you Gaps-in-Care Reports for assistance.
As a reminder, you can access up-to-date panel lists for your practices on our secure web portal. You can also upload Medical Records for HEDIS Medical Record Review.
If your practice is not registered for the secure web portal or the Member Care Information portal, just complete and fax the registration form to Provider Relations at 1-860-607-7485.
The registration form can be found here.
Emergency Department (ED) claim review policy and diagnosis codes
Effective November 1, 2016, Aetna Better Health will apply our Emergency Department (ED) claims review policy to Medical Assistance and CHIP claims.
You can find the list of emergency room diagnosis codes that will automatically allow claims to process without severity medical record review attached to the ED policy provider notice, here.