Notes

(02) 789-9999

A - EPDB
B - MEM
C - SCDI
D - ACAS
E - SCM
F - CRS
G - EWMP
M360- eligibility and benefits; many tabs
P360- less tabs

Walmart- ends with "W"

===============================
ALWAYS ASK FOR CPT CODE

EPDB
-Enterprise Provider Database

ACAS
-ei
-8a
Aetna Standard Table
procedure code: J0636 43634
is allowed when billed for dx code
diagnosis code: V416
diagnosis driven
rule type: A
Clinical Policy Bulletin

Maternity
initial
pre natal
hospital
pre cert

we follow 3-5 day rule for normal and
c section delivery

MODALITIES
FUNDING ARRANGEMENT
AND OFFICE

===============================
GROUP#

new tax ID not updated so if
old TIN is used onfi might be inaccurate
===============================

PST = Plan Sponsor Team

PLAN TYPE:
Traditional:
-PPO
-Exclusive Provider

PPO-In network no out of network benefit
(REQUIRES REFERRAL)
>Aetna Select-Primary Product
>Elect Choice-Primary Product

OA
-Open Access to all provider
-with add ons first
-no referral needed

Indemnity (CMED/Major/Basic Primary

Product)
>almost out of network
>low coverage
>50,60,70%
>low customization

NON-Gated Plan
>Indemnity (CMED/Major/Basic Primary

Product
>Open Choice PPO-Primary Product

RAHPS Policy
> kahit out of network covered as in network

PCP
-Primary Care Physician

PLANS:
Elect Choice (EPO) - in network
Open Choice (PPO)
Managed Choice (POS) - needs referral
Choice POS II
Open Access Elect Choice
Open Access Managed Choice (POS)
Health Fund
Aetna Select
Open Access Aetna Select
Indemnity - Reasonable and customary per

state

Aexcel-Add ons

Aexcel Providers: elite
12 SPECIALTY TYPES:
Cardiology
Cardiothoracic Surgery
Gastroenterology
OB/GYN
Orthopedic
General Surgery
Neurology
Neurosurgery
Otolaryngology
Plastic Surgery
Urology
Vascular Surgery

Designated- Top of the line
non-designated- middle class aexcel

Exempt-non-aexcel
Standard-non-designated; middle class
Maximum-designated; lower member's

responsiblity

Aetna HealthFund
•Provide affordable and accessible health

benefit options
•Help control medical costs
•Promote use of cost-appropriate care

HSA- Health Savings Fund
-employer and member can deposit funds

Health Reimbursement Arrangement (HRA)
>The Health Reimbursement Arrangement

(HRA)
is an employer-paid fund that is combined

with a
deductible-based medical plan. The

underlying medical
plan does not need to be a high-deductible

health plan
(HDHP), but typically does include a high

deductible
($1,000.00 to $3,000.00). The fund is

normally used to
cover traditional medical plan expenses.

Optional pharmacy
and dental benefits may also be integrated

with the plan
or have a standalone HRA.

Aetna Select-Primary Product
is same as Elect Choice-Primary Produc

Indemnity Add on:
Major Medical
Basic Medical
Comprehensive Medical
Executive Medical

in network
out of network
ext vendor

BENEFIT
COVERAGE
DEDUCTIBLE
coinsurance
benefit arrangement
out of pocket

gated=specific; guided contract
non-gated=default

External vendors OON:
•MultiPlan
•National Preferred Provider Network

(NPPN)
•FedMed
•Beech Street
•Three River Provider Network (TRPN)

Narrow Networks
-no reciprocity
-exchange plan

EXCHANGE

Plan/Marketplace/OBAMACARE
/Health Care Reform Plan

Off exchange

Plan sponsor tool = Home host Provider
HOSPITAL VERTICAL ACCOUNT
(COLOR GRAY)=Transfer

Innovation Health = Transfer

Reciprocity
Modified – Effective 10/28/08
Under reciprocity, members receiving care
from a participating provider in another PPO
network are entitled to preferred benefits
and discounts. The most common reasons

are:
-Dependents who are away at school, and
-Members who for various reasons are

away
from their homes (e.g., on business or
vacation) and can't return for medical care.

4 members per call

AHF-Aetna Health Fund

IN network?
-check network ID if same YES
-if no Check reciprocity

I can see that you are in network with aetna

however let me just check if your still
in network with the member's specific

account

OUT OF NETWORK= AUTO No COPAY
In NETWORK= WITH COPAY

Docfind.com

HNO -Client Specific Restricted page
Health Network Option Transfer Code

===================
eligibility
•Update provider details in the Smart Front

End system.
-Transfer

•Demonstrate navigation within MEA

system.
-B rumba

RUmba
ctrl W-reset
F8-next page
F3- Back/ prev page

Enhanced Clinical Review (ECR) Program
- Traditional Customer Service

PLAN TyPE
PLAN SPONS TOOL
IN/OUT Network
active?
funding arrangement
facility/office vist

DIAG XRAY LAB
-Free standing Facility
-Hospital
-Ambulatory

PCP COPay
-PCP in Office

CHiro
-spinal manipulation

NO modalities
-fully funded
-hospital
self funded

4 modalities/day
-self funded
office visit
limit 25 visit
azfter 25 visit subject to medical necessity

review

New Style
-80%

Old STyle
-separate benefits

PT old style
-hospital
-place service
-home
-office

New Style
-any place of service would fall short term

rehab

1. get code and check with rumba
2. who? what, where?
3. precert look up tool- quote
ACAS
BENEFIT
REVIEW
*asterix no exclusion

HOSPITAL
-FACILITY CHARGE/ PROFESSIONAL

CHARGE
oFFICE
-PCP/SPECIALIST

if Old style quote thera admin
if new style quote spinal manipulation

if Old styleplace of service
if new style short term

we dont handle dental except oral surgeryD

OON-does not require precert

NON-PAR
-1995 Precert

Radiology Managed Service Org.(EPDB)/

ECRP (ASD)
-verify if procedure req PRECERT thru

rmso vendor
-IN Network


ECRP (Enhanced Clinical Review Program)

not applicable
=precert not required

D_ACAS=Aetna Standard table

what specific benefit
cpt code

pull up
1. m360
2. PST
3. ACAS
4. SCDI

-Enter
-MRNAV1A
-MRCLP1
-CLPROCES
-PSRCINQ
-PSRCDI

IF mEDICARE IS pRIMARY NO NEED FOR

PRECERT FOR INPATIENT

MATERNITY
FIRST 3 DAYS NO PRECERT REQUIRED

FOR nsd
C SEC FIRST 5 DAYS

NEWBORN
COVERED FIRST 31

benefits
-CPT DRIVEN DX
-PLACE
-PHYSICIAN
-COPAY
-COINS
-DEDUCTIBLE

IOE/physician add

what to Quote for Mental health
(LOC) LEVEL OF CARE
-Inpatient
-Outpatient
-(PHP)partial hospitalization/Outpatient
-(IOP) Intensive Outpatient
-Residential
OON
-check 1995

DME
rent to own-10 mos
e0601

no orthotics line
-check diagnosis code
-check diabetic mandate
-check dura

IF PROVIDER WANTS TO CHECK

COVERAGE
precert look up, diag code?
acas
benefit in asd

new dme or
repair covered?
-depends on the invoice. (affordable)

precert is requires thru medsol
high
diag

OON
-check 1995 in oon
-no precert for high tech/ complex imaging

PAY FOR CPB DX, DD, & AUTISM TO AGE

18

PANASONIC CORPORATION OF NORTH

AMERICA
SPEECH THERAPY 2

epdb> prov name> ProOrg: A

VALIDATION:

10 T ID:
9 digits NPI:
pin 7 digits

PROVIDER'S NAME:

ADDRESS:

*MM ID/SSN:

Name:

*DOB :

-"for billing purposes let me
verify again the DOB"
ADDRESS
PHONE
Plan sponsor tool
Check if par/non-par = Network ID

and that deductible applies toward the
out of pocket limit of

MATERNITY
-SPECIALIST COPAY-INITIAL VISIT
-PRE-Natal-maternity benefit
-FOR DELIVERY itself-hospital
-CONFINEMENT COPAY

exempt d/nd

CHIROPRACTOR/SPECIALIST
-EVALUATION OF MANAGEMENT

PHYS ADD
-PT EVALUATION

SECONDARY TO MEDICARE
-NO PRECERT REQUIRED ONLY

NOTIFICATION
-TIMELY FILLING VOIDED

IN NETWORK
TIMELY FILING
-120 DAYS PROFESSIONAL
-FACILITY 365

OON
-2 YRS 90 DAYS.