Together, we can improve health care quality
For PA Medicaid Closure Information, please visit Provider Experience Educational Resources. Click on "Provider Reference Information.
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.
CME/CEU Credit Opportunities-Pediatrics, Obesity
Provider Policy Updates
Urgent FINAL NOTICE - Complete PROMISe ID and service location revalidation
Important update: June 16, 2016
The Commonwealth of Pennsylvania’s Department of Human Services (DHS) that DHS intends to enforce the Provider Enrollment and Screening Provisions of the Affordable Care Act (ACA) (§ 455.414).
We want to make all providers aware that DHS enforcement of the provider enrollment and revalidation requirement will begin on August 28, 2017.
Please ensure you have met all of the enrollment requirements, including revalidation of your PROMISEe ID, to avoid termination from the Aetna Better Health of Pennsylvania network. Below is helpful revalidation information that was previously sent to all providers earlier this year.
See the Full Provider Notice from Aetna Better Health.
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.
Duplicate Remittance Advice Requests
As of March 15, 2017, Aetna Better Health will no longer supply duplicate remittance advice (RA) requests telephonically. Duplicate remittance advice (RA) requests can be accessed through our secure web portal.
Access our secure web portal for RA information
RAs are located on our secure web portal. It is the provider’s responsibility to download and/or print and save these payment registers. We will no longer reprint RAs for providers.
How to get the information you need
- Log in to the secure portal to access your RA documents
- Download and/or print and save your RA documents for:
- Payment reconciliation
- Required documentation retention purposed
- Arrange to supply these documents or give access to these documents to contractor/vendors working on your behalf
Our secure web portal also lets you:
- Check member eligibility
- Check claim status
- Submit authorizations online
- Access real time data and reports
Not yet registered? It’s easy!
- Go to our provider portal
- Click on Secure web portal
- Click on registration form
- Download, complete and sign the registration form. Then, just fax the completed form to Aetna Better Health at 1-860-607-7485.
Need additional help?
You can contact provider relations at 1-866-638-1232 for assistance. Select option 3, and then option 5. We’ll walk you through the process to get you registered right away. And answer any other questions!
Children’s Dental Health and the Primary Care Physician
Primary care providers (PCPs) are on the front line to help prevent pediatric tooth decay. We know learning good dental health habits early is an important part of overall health for children and adolescents.
Although many infants and toddlers have not seen a dentist, most see their PCP and other non-dental providers such as nurses and specialists. Each of these visits is an opportunity to screen for tooth decay, gum inflammation and oral abnormalities. PCPs are on the front line to provide anticipatory guidance to their patients to influence healthy behaviors and limit exposure to oral disease. And remember, topical fluoride varnish can also be done by a PCP or CRNP in the office.
Children should begin a program of regular preventive dental care by visiting a dentist, starting at the eruption of the first tooth, but no later than age one. Early childhood caries is one of the most common pediatric infectious diseases. PCPs should encourage and guide children and their parent/guardian toward a lifetime of oral health by advising a visit to the dentist, and referring to a dental home.
The American Academy of Pediatrics Healthy Teeth, Healthy Children program offers an oral health training program for pediatric practices.
Your practice can learn
- How to increase revenue though additional reimbursement
- How to obtain and apply fluoride varnish
- How to implement Bright Futures Oral Health Recommendations
Contact the Healthy Teeth, Healthy Children program 484-446-3059 or email@example.com for more information.
Aetna Better Health and Aetna Better Health Kids members have dental benefits through SKYGEN USA. Please encourage your patients to schedule a dental visit with a SKYGEN USA dentist. For questions about dental benefits or to find a network provider, call SKYGEN USA Member Services at:
Visit the Pennsylvania Dental Association website for free online dental resources: https://www.padental.org/Online/Resources___Programs/NCDHM_/NCDHM_Homepage.aspx
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.
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.
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.
Electronic Visit Verification
Electronic Visit Verification (EVV) – URGENT Reminder
The Pennsylvania Department of Human Services issued a mandate effective January 1, 2021 regarding verifying home health personal care visits electronically. Aetna Better Health of Pennsylvania (ABHPA) is partnering with Sandata. Sandata will collect the EVV information, verify that required elements are present and then send that information to ABHPA.
Failure to submit EVV data will impact our ability to process your claims for payment. Claims will deny, when the EVV data is missing. Please ensure you are billing correctly, that you are submitting your EVV data to a vendor of your choice and that your vendor is submitting your data to Sandata.
Please note: If your agency has more than one 9-digit Master Provider Index number (MPI#), testing must be done for each MPI#. Additionally, you must ensure all electronic visit verification data is submitted back to January 1, 2021.
If you have any questions or concerns related to data submission please contact Sandata at 1-855-705-2407 and submit a ticket.
Below are resources to better help you understand the DHS mandated Electronic Visit Verification requirements for home health personal care visits.
Change In Prior Auth_PCS_T1019
OMAP PH MCO EVV Authorization Process V1.4
Home Health Personal Care Electronic Visit Verification Mandate
Electronic Visit Verification Overview Addendum - 1