Aetna OfficeLink Updates All Regions

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March 2018Aetna OfficeLink Updates All regionsInside this issueChanges to our NationalPrecertification ListReminder for Coventry providers2–3Clinical payment and codingpolicy updates4–5Office newsBehavioral health6–89 – 10Medicare10 – 12Pharmacy12 – 13State-specific articles13 – 1595.22.800.1-MAR (3/18)We no longer publish the Coventry provider newsletter. The AetnaOfficeLink UpdatesTM newsletter will now serve all our providers.To sign up for electronic communications, including Aetna OfficeLinkUpdates, log in to our secure provider website and select “Aetna HealthPlan” from the workflow menu. Choose “Email Options,” then “Share EmailAddress.” Enter your email address and review the email acknowledgment.aetna.com

Changes to our NationalPrecertification List (NPL)Note: We encourage you to submit precertification requests at least two weeksbefore the scheduled services.Effective July 1, 2018, the followingprecertification changes apply: We’ll require precertification for CalcitoninGene-Related Peptide (CGRP) receptor inhibitors We won’t require precertification for the following:- Anti-emetic drugs/medical injectables, includingEmend IV (fosaprepitant dimeglumine)- Observation stays more than 24 hours (for moreinformation, see the observation policy entryin the policy chart)- Power MorcellatorThe following new-to-market drugsrequire precertification: Yescarta (axicabtagene ciloleucel) — precertificationeffective January 2, 2018. This drug is included in thechimeric antigen receptor T-cell therapy drug class. Durolane (hyaluronic acid) — precertification effectiveFebruary 2, 2018. This drug is included in theviscosupplements drug class. Fasenra (benralizumab) — precertification effectiveFebruary 9, 2018. This drug is included in therespiratory injectables drug class. Mepsevii (vestronidase alfa-vjbk) — precertificationeffective February 9, 2018. This drug is includedin the enzyme replacement drug class.You can find more information about precertification under the General Information section of the NPL.Aetna is the brand name used for products and services provided by one or more of the Aetna group ofsubsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).2

Request precerts electronically — it’s fast,secure and simpleRemember to request precertification electronically.* It’s our standard practice. Andwhen you do, you won’t have to worry about calling the correct number or waiting on hold.Submitting precertification requests online is faster and easier than calling. And you cansubmit requests at your convenience.How to get startedWe’re here to helpTo submit electronic precertification requests, pick a vendorfrom our list of approved vendors. Or register for anduse NaviNet , our secure provider website. You don’t evenhave to be participating to register for or to use the site. Butif you’re participating, you can access administrative tools.We offer live webinars to teach you how to submitprecert requests electronically. Follow the instructions inthe How to Register for Webinars section to register. Oryou can email us for help.*In accordance with Medicare regulations, we’ll continue to accept precertification requests initiated by phone formembers enrolled in Medicare plans.3

Clinical payment and codingpolicy changesWe regularly adjust our clinical payment and coding policy positions as part of our ongoing policy reviewprocesses. Our standard payment policies identify services that may be incidental to other services and,therefore, ineligible for payment. In developing our policies, we may consult with external professionalorganizations, medical societies and the independent Physician Advisory Board, which advises us on issuesof importance to physicians. The chart below outlines coding and policy changes.ProcedureEffective dateWhat’s changedObservationpolicy*July 1, 2018Observation services are the use of a bed and periodic monitoring.It consists of short-term treatment by a hospital’s nursing or otherstaff. The use of the observation treatment evaluates a patient’scondition to determine the need for possible inpatient admission.Since July 1, 2015, observation stays greater than 24 hours requirednotification or we applied a late notification penalty. As of February 1, 2018, for all states we no longer apply a latenotification penalty to your facility. Working with our providerpartners, we’re updating our policy to make the steps clearer andeasier to follow.Starting July 1, 2018, we are updating our policy as follows: We no longer require notification for observation greater than24 hours We no longer cover observation services that extend beyond48 hoursEligibility ofassistant surgeonsand surgicalassistantsJune 1, 2018Starting June 1, 2018, we will make changes to some of theprocedures we consider eligible for assistant surgeons and surgicalassistants for Coventry commercial and participating Medicareclaims, in accordance with Aetna’s current policy.Expanded claimsedits*June 1, 2018We notified you in December that we expanded our claims editingcapabilities by adding new third-party claims edits. We areimplementing additional edits effective June 1, 2018.To view these edits, check our secure provider website forinformation. You’ll have access to a new prospective claims editingdisclosure tool available on our secure provider website. Afteryou log in, go to Plan Central Aetna Claims Policy Information Policy Information Expanded Claims to find out if our new claimsedits will apply to your claim.*Washington state providers: This item is subject to regulatory review and separate notification.4

Multiple procedure reductions for therapy servicesIn December, we issued a reminder about our multiple procedure reductions for therapy. This reminder included an effectivedate, but it should not have. We are not changing our policy. Our intent was to provide a reminder of our current policy.Reminder: We apply multiple procedure reductions to certain therapy services.We payWe reduce the PE RVU portion of the total RVU by100%of the therapy service with the highest practiceexpense (PE) relative value units (RVUs).50%for subsequent therapy services performed on the same day.Coverage determinations Share our diseaseand utilizationmanagement programsmanagement (UM)with membersWe use evidence-based clinical guidelines from nationallyrecognized authorities to make UM decisions. We reviewrequests for coverage to see if members are eligible forcertain benefits under their plan. The member, member’srepresentative or a provider acting on the member’s behalfmay appeal this decision if we deny a coverage request.Our UM staff helps members access services covered bytheir benefits plans. We don’t pay or reward practitionersor individuals for denying coverage or care. We base ourdecisions entirely on appropriateness of care and serviceand the existence of coverage. Our review staff focuses onthe risks of underutilization and overutilization of services.Clinical policy bulletins (CPBs) and pharmacyclinical criteriaOur disease management programs provide educationalmaterials and, in some cases, one-on-one contact withnurses in the program.The programs help members self-manage their disease.They help members better understand their conditionand their doctor-prescribed treatment plan. The programsalso educate members on accepting lifestyle changes thatcan help them achieve their health goals.Enroll todayTo enroll a member in a disease management program,just call Member Services. The number is on the back ofthe member’s ID card.We determine whether certain services, medications orsupplies are medically necessary, experimental,investigational or cosmetic. This helps assess whetherpatients meet our clinical criteria for coverage. CPBcriteria can also help you plan a course of treatmentbefore calling for precertification, if required.Learn moreOur medical directors are available 24 hours a day forspecific UM issues. Contact us by: Visiting our website Calling Provider Services at 1-800-624-0756 Calling patient management and precertification staff usingthe Member Services number on the member’s ID card5

Office newsOur office manualkeeps you informedOur Office Manual for Health Care Professionalsis available on our website. For Innovation Health,once on the website, select “Physicians &Providers,” then “Practice Resources.”Visit us online to view a copy of your manual as well asinformation on the following: Our adopted clinical practice guidelines and preventiveservices guidelines, which address preventive, acuteand chronic medical and behavioral health services.Find them on our secure provider website. Select“Clinical Resources” from Aetna Support Center. Policies and procedures Patient management and acute care Our complex case management program, including howto refer members How to use disease management services and how wework with your patients in the programsAs our national preferred provider, QuestDiagnostics is committed to improving efficiency.So you’ll get the diagnostic information you need. Special member programs and resources, including theAetna Women’s HealthSM program, the AetnaCompassionate CareSM program and othersThis lab: Member rights and responsibilities How we make utilization management decisions,including our policy against financial compensation fordenials of coverage Medical records criteria — a detailed list of elements werequire in a patient’s medical record Offers a complete menu, from high-quality, routinelaboratory testing to advanced genetic, molecular andother specialty tests Can perform more than 3,500 tests, with expertise incancer, cardiovascular and infectious diseases,neurology and more Employs more than 700 MDs, PhDs and genetic counselors The most up-to-date Aetna Medicare PreferredDrug Lists, Commercial (non-Medicare) PreferredDrug Lists and the Consumer Business PreferredDrug List, also known as our formularies Helps patients lower their out-of-pocket costs How our quality management program can help youand your patientsQuick tipsWe integrate quality management and metrics into allthat we do. You can find details on the program goalsand the progress made toward those goals online.If you don’t have Internet access, call our ProviderService Center for a paper copy of the manual.6Quest Diagnostics benefits you andyour patients Offers new access in retail locations, like Safeway andWalmart, in some regions Get fast, easy access to patient test information withQuanum eLabs. Just get started here. Call 1-866-MY-QUEST (1-866-697-8378) to set up anaccount or to get more information. Check our Clinical Policy Bulletins before orderingtests to see if we cover them. This may help yourpatients avoid out-of-pocket costs.

Aetna 2018 HEDIS data collection is under wayOur staff or our contracted representatives — CIOX and Verscend — will soon be contacting your office tocollect medical record information on behalf of our members. We appreciate your cooperation.Why this is necessaryWhat we may need from youHealthcare Effectiveness Data and Information Set (HEDIS )data collection is a nationwide, joint effort amongemployers, health plans and physicians. The goal is tomonitor and compare health plan performance as theNational Committee for Quality Assurance (NCQA) specifies.If we contact you, we’ll ask you for timely access to ourmembers’ medical records. Our contracted representativeswill give you options for sending medical records.How to update dataabout your officeOrdering genetic tests inthe correct sequence willresult in fewer denialsTo update your office’s demographic information, goto our secure provider website or use one of ourvendors (Availity or CAQH) that have reached out toyour office. You should notify us whenever the followinginformation changes: Email and mailing addresses Phone or fax numbers Name changes due to marriage or another life event Whether your office is accepting new patients Hospital and group affiliationsIf you’ve been calling our Provider Service Center tomake these changes, we ask you to use the secureprovider website instead. The site lets you confirm theinformation you submit. It also prevents unauthorizedindividuals from submitting incorrect information aboutyour office or facility.The Centers for Medicare & Medicaid Services (CMS)requires Medicare Advantage plans and Qualified HealthPlans (QHPs) to maintain accurate directories. Havingyour up-to-date information allows us to do that.We appreciate your help in our data collection efforts.We want to remind you about our policy oncomparative genomic hybridization (CGH). Wecover CGH, but only if it meets certain criteria.Often we see providers ordering CGH and targetedgenetic testing at the same time. But one of the criteriafor covering CGH is a negative result for the targetedtest. A common example of a targeted genetic test isFMR1 gene analysis for Fragile X. We often see FMR1ordered at the same time as CGH. Without a negativeFMR1 result, and without also meeting the other criteria,we won’t cover CGH, and the member will end up with asignificant bill.Ordering these tests in the correct order should lead tofewer denials and appeals.Read more about our CGH policy.Electronic transactionsYou also can do most electronic transactions throughthe secure provider website. This includes submittingclaims, checking patient benefits and eligibility, andrequesting precertifications.NaviNet security officers have access to Aetna’s “UpdateProvider Demographics” function, through which they cansubmit demographic changes. They also can authorizeother users’ access to this feature as appropriate. To usethe secure website, you must register first.7

Tips to help youspot — andprevent — fraud2017 medical record auditThese days, everyone has to stay on top of their gameto avoid being a victim of fraud. Yes, even providers.Follow these helpful tips.Audits are conducted every two years to ensureprimary care providers’ compliance with medicalrecord documentation.Pharmacies can get patient IDsCriteria:That’s right — through phishing schemes. Don’t assumethat the request you get means the pharmacy has anestablished relationship with your patient. Medical record content and organization of the records When you get a fax, check the patient’s records toconfirm that the patient uses the pharmacy. Contact patients when you get requests fromunknown pharmacies. Watch for requests for excessive quantities. When there are questions regarding formularyinterchange and alternatives, contact the plan.With diabetic supplies, beware of faxes that: Require your office to uncheck unwanted supplies Don’t indicate your patient’s type of machine or stripsReview requests for topical products carefullyLidocaine 5 percent ointment is for acute use only. Butmany pharmacies are requesting excessive amounts.Beware of: Preprinted forms requiring you to pick a compound Preprinted faxes with multiple topical products prepacked Faxes for compounds or products comprised of severalmedications available as individual productsTake extra precautions with prior authorizationsSometimes third parties may give misleading clinicalcodes or clinical support for prior authorization. If you’rein an agreement with a third party to perform priorauthorization, confirm that the information is correctbefore you sign anything.8Our overall national compliance score for 2017 is 92.1%,which exceeds our performance goal of 85.0%. Allregions met the goal. Confidentiality of patient information Performance goals for participating practitionersThe following opportunities for improvementwere identified: Current immunization records for children orimmunization history for adults Follow-up care, calls or visits with the specific time ofreturn noted (e.g., weeks, months) Advance directives, located in a prominent part of themedical record, for patients 18 years and older Documentation that preventive screenings and servicesare offeredYou can find the specific documentation criteria in theOffice Manual for Health Care Professionals, found onour provider website at aetna.com.

Behavioral healthAlcohol Screening,Brief Intervention andReferral to Treatment(SBIRT) programOur SBIRT program is designed to support primary carephysicians (or other specialty physicians such as ob/gynphysicians or internal medicine physicians) in screeningpatients for alcohol abuse, providing brief interventionand referring individuals to treatment. Overall, theprogram aims to improve both the quality of care forpatients with substance abuse conditions, as well asoutcomes for patients, families and communities.Our goal is to help increase the adoption of alcoholscreening, brief intervention and the referral totreatment process in primary care physician practices.The program incorporates the evidence-based protocolestablished by the National Institute on Alcohol Abuseand Alcoholism (NIAAA). We reimburse you for screeningand brief intervention. This program is open to Aetnaparticipating physicians treating any patient who is 18years of age or older and has Aetna medical benefits.Click here to get started.There is an app for thatThe SBIRT app is now available as a free download onthe App Store for iOS devices.The app provides evidence-based questions to screenfor alcohol, drugs and tobacco use. If warranted, ascreening tool is provided to further evaluate the specificsubstance use. The app also provides steps to completea brief intervention and/or referral to treatment for thepatient based on motivational interviewing.Opioid overdoserisk screeningprogramOur behavioral health clinicians screen behavioral healthmembers to identify patients at risk of opioid overdose.Any patient receiving a diagnosis of opioid dependenceis considered to be at risk. Learn more about theopioid epidemic.How you can helpConsider naloxone as part of the treatment plan forpatients at risk of an opioid overdose. Naloxone reversesthe effects of an opioid overdose. Giving naloxone kits tolaypeople reduces overdose deaths,1 is safe2 and is costeffective.3 Other elements supporting this potentiallylife-saving intervention include telling patients and theirfamily/support network about signs of overdose andabout administering medication.Coverage of naloxone rescue kits varies by individualplans and can be verified by calling the number on themember ID card. Note that as of January 1, 2018, we’llwaive copays for the naloxone rescue medicationNarcan for self-insured commercial members.Resources to help you and your patients Aetna opioid resources Centers for Disease Control and Prevention:providing naloxone to laypersons SAMHSA: opioid overdose toolkitKerensky T and Walley A. Opioid overdose prevention and naloxone rescue kits: what we know and what wedon’t know. Addiction Science & Clinical Practice. January 7, 2017; 12(4). https://doi.org/10.1186/s13722-016-0068-3.12Walley A, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasalnaloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013; 346: 1 – 12.3Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann InternMed. 2013; 158: 1 – 9.9

Depression screening for pregnantand postpartum womenAetna Behavioral Health works with Aetna Medical Management to assist in identifying depression andbehavioral health factors for pregnant women. Aetna’s Beginning Right maternity program provideseducational support to members and providers. The program helps women reach their goal of a healthy,full-term delivery.Program elementsHow to contact us The clinical case management process focuses onmembers holistically. This includes behavioral healthand comorbidity assessment, case formulation, careplanning and focused follow-ups. Members and providers can call1-800-CRADLE-1 (1-800-272-3531)to verify eligib

CPB criteria can also help you plan a course of treatment before calling for precertification, if required. Learn more . Our medical directors are available 24 hours a day for specific UM issues. Contact us by: Visiting our . website Calling Provider Services at . 1-800-624-0756

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Select Health Care Professionals Select "Log In/Register" If you have questions after viewing the information online, call us: 1-800-624-0756 for HMO-based and Medicare Advantage plans 1-888-MDAetna (1-888-632-3862) for all other benefits plans 00.22.811.1 W (11/15) www.aetna.com December 2015 Volume 12, Issue 4 Aetna OfficeLink .

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