Link. Office. Updates. Aetna. Introducing Aetna Health Network Option SM and Aetna Health Network Only. And the winners of a Dell computer are

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1 NORTH CENTRAL REGION Aetna Office Updates VOLUME 4, ISSUE 3 Link JUNE 2007 Inside This Issue Policy & Practice Updates Aetna s Education Site for Health Care Professionals Plan Facts & Features Prescription Medications & Pharmacy Management Physician Focus OfficeWise Striving for Quality Excellence North Central News Introducing Aetna Health Network Option SM and Aetna Health Network Only Aetna Health Network Option and Aetna Health Network Only are HMO-based, open access plans. Aetna Health Network Option will be available beginning July 1, 2007; Aetna Health Network Only will take effect January 1, For these plans, referrals will not be required for members to access care from participating specialists. PCP selection is strongly encouraged, but not required. All current administrative processes you follow for our other HMO-based benefits plans remain similar for these plans. Provider reimbursement will also be the same as our existing HMO-based products. With these plans, we will begin consolidating our Explanation of Payment (EPP) format into one common format for all our products. How to recognize these plans The member ID card will show the plan as either Health Network Only or Health Network Option. The term Health identifies members as HMO members and represents the Aetna network from which they can choose doctors and hospitals. Network Option signifies that the member s plan has both an in-network benefit and the option to go outside Aetna s network for care. Network Only means the member has coverage for in-network care only, with no out-of-network coverage. These plans will be offered to new employers in all current HMO states except California and Washington. And the winners of a Dell computer are Congratulations to Sharon Andree of New Stanton, PA, and Dr. John W. Sensenbrenner of Charlotte, NC. For registering on Aetna s provider preference website to receive electronic communications from us, Ms. Andree and Dr. Sensenbrenner are the lucky recipients of a Dell computer system. The winners were selected at random from a total of 5,384 registrants to the provider preference site. Both winners currently receive Aetna OfficeLink Updates via and find it very helpful. It s right there, says Sharon Andree of BCMI, Inc. in Pennsylvania, regarding the OfficeLink Updates newsletter in her inbox. Dr. Sensenbrenner s billing representative, Stacy Offnick, of Sensenbrenner Primary Care in North Carolina also finds communications valuable. When asked Does having the option of electronic communications make doing business with us easier? her immediate response was, Yes less paper. Congratulations again, and thanks to everyone who entered the drawing. And for those who haven t already done so, sign up at today and begin receiving electronic communications NC (6/07)

2 Policy & Practice Updates Clinical, payment and coding policy changes We regularly adjust our clinical, payment and coding policy positions. In developing our policies, we may consult with external professional organizations, medical societies and Aetna s independent Physician Advisory Board, which advises us on issues of importance to physicians. The chart below outlines recent coding and policy changes. Code(s) Impacted Procedure What s Changed Implementation Date A4554 Supply: Disposable underpads, all sizes, for example, Chux s This procedure code does not represent a medical supply and, therefore, is not covered under Aetna s medical plans. In the past, we may have reimbursed this code when billed as part of a home care program, but coverage will no longer be provided in these or any other situations. September 1, 2007 Coding practice reminders: New CPT code for balloon sinuplasty S2344 became effective January 1, The code description is not specific to the sinus involved. Therefore, when billing for balloon sinuplasty, please bill the appropriate endoscopic sinus procedure CPT code from the 312XX series that is specific to the sinus involved. Bill only for one unit CPT code describes multiple allergenic extracts administered at a given patient encounter. The appropriate billing for CPT code (professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections) is one unit only, regardless of how many injections are given. Letting members know when their provider leaves the network Aetna is now informing members who may be affected whenever a provider leaves the network. Providers may also continue to notify their patients of their termination with Aetna. We are amending our provider agreements to remove the requirement that network physicians must inform members they have treated when they leave Aetna s network. New language will be included in all new physician contracts with PCPs, specialists, independent practice associations (IPAs), physician group agreements (PGAs) for groups with fewer than five physicians, physician hospital organizations (PHOs) and behavioral health specialists. The language states that once Aetna is notified of a physician s intent to terminate their contract, Aetna is responsible for providing notice of the impending termination to any members who were treated by the provider within the previous 12 months. Notification must be done before the effective date of the termination or as soon as possible in the event of immediate termination. Patient Social Security numbers no longer on EOBs To protect the privacy of our members, beginning September 7, 2007, patients Social Security numbers will no longer be listed on provider Explanation of Benefits (EOB) statements. You can still search for or match a patient without using his or her Social Security number. Simply use other information on the EOB, such as the patient account number or member ID. 2 Aetna OfficeLink Updates June 2007

3 Aetna s Education Site for Health Care Professionals LEARNING OPPORTUNITIES FROM AETNA...DEVELOPED WITH YOU IN MIND Open a window into your patients health history It s easy, with Aetna s Personal Health Record, which keeps all of a patient s health information up to date and in one place. The Personal Health Record includes data from claims such as lab results and the names of other medical providers the patient may have seen and allows patients to add other information, like family health history, over-the-counter medications taken or allergies. So it s simple for patients to keep track of and share their personal health information with you. The result: a more complete picture of your patient s health, which means you can better coordinate care. We invite you to view the sample Personal Health Record under Reference Tools and encourage your patients to update and share their Personal Health Record with you. Your Aetna patients can access and update their Personal Health Record through Aetna Navigator, our secure member website. COURSE HIGHLIGHTS Health care is changing A new direction is under way in health care that affects you and your relationship with patients. It s called consumerism, and it s poised to cause a significant shift in the health care industry. Consumerism offers patients greater responsibility and control over decisions affecting their health care. It provides them with performance and pricing information about physicians and medical services that can help them make better informed choices when spending their health care dollars. Because patients have more skin in the game, consumerism encourages them to be more active participants in their care. Get started now! Since launching our education site last year, more than 9,000 physicians and office staff have visited the site and taken courses. This tells us that we re offering the tools and resources you ve said you need to conduct business with us and help improve your patient interactions. In fact, our Education Site for Health Care Professionals was recently honored with an Award of Merit in the World Wide Web Health Awards competition, which recognizes the best Web-based health-related content for consumers and professionals. Consumer-driven care plus informed, motivated patients equals better physician-patient relationships. To learn more about the key factors that have led to consumer-directed health plans, enroll in the Changing Health Care Marketplace course today. Helping you interact more effectively with different ethnic groups To help you in caring for patients of various ethnic and minority groups, we are offering free access to continuing medical education (CME) and continuing education unit (CEU) courses developed by the Manhattan Cross Cultural Group (MCCG). We invite you to join the crowd and discover the education, tools and resources we ve developed with you in mind. Visit us today: Log in to our secure provider website. Choose the Education link on the top navigation bar, then Main Page to reach the Education home page. Select Enter to enter the Education site. These Quality Interactions courses designed specifically for general practitioners, oncologists and nurses present a patient-based approach to cross-cultural care. The courses include interactive case studies with patients in a clinical setting and teach skills for administering more effective cross-cultural care. We also offer refresher courses and a free, non-accredited course for non-clinical medical office staff. Take advantage of these Quality Interactions courses. June 2007 Aetna OfficeLink Updates 3

4 Plan Facts & Features Tips for faster Medicare payments when Aetna is the secondary payer No one wants to waste time or money submitting unnecessary claims. So, before you submit your next Medicare Part B claim to us as the secondary payer, follow these five simple steps to avoid submitting duplicate claims: Don t send a bill to us. When you file Part B claims with Medicare and Aetna is the secondary payer, Medicare pays its share of the claim and, in most instances, automatically forwards the claim information and any remaining balance to us for payment consideration, electronically. Use the electronic Claim Status Inquiry tool. This transaction on our secure provider website can help you determine if we already received your Medicare claim. Look for the MA18 code. Review your Medicare Explanation of Payment remittance to see if it displays the code MA18, which indicates your claim was automatically forwarded to a secondary payer such as Aetna. Make a note that Aetna is reviewing your claim. After posting Medicare s response to your accounts receivable system and assigning responsibility for the remaining balance to Aetna, choose the option that works best for your office s processes: Suppress billing us for 30 days. Medicare carriers send secondary claims every 7 days, and we pay clean claims promptly. Create the paper claim if your system cannot suppress billing, but do not mail it to us. Follow up in 30 days, if needed. If you haven t received payment from us in 30 days from the date of Medicare posting, check on your claim via: Our secure provider website. Our self-service telephone system, Aetna Voice Advantage. Your current electronic data interchange (EDI) vendor. Collect copays for Part D covered vaccines Physician offices should collect a payment from Aetna Medicare members for the cost of Part D covered vaccines at the time of service. Most Medicare Part D carriers cannot issue payment to physicians because Part D is a drug plan. The vaccine administration fee should continue to be billed to Aetna if the member is enrolled in an Aetna Medicare Advantage plan that includes Part D coverage. If the member is enrolled in an Aetna Medicare Advantage plan that does not include Part D coverage, the vaccine administration fee is not covered. If the member s Aetna plan includes Part D coverage, he/she will need to submit an itemized claim and proof of payment to Aetna Pharmacy Management to be reimbursed for the vaccine charges. We ve posted an online chart indicating which vaccines are covered under Part B vs. Part D coverage. Please visit or our secure provider website for further details. Search for the vaccine coverage document under Medicare Advantage Plans. Medicare fee-for-service administration made easier We have added information to our websites to help you navigate our new Medicare private fee-for-service (PFFS) plan: the Aetna Medicare Open SM Plan. This information includes: $0 copayment grid for preventive services. Vaccine grid with information about Part B vs. Part D coverage. Expanded Aetna Medicare Open Plan reimbursement grid. Expanded Aetna Medicare Open Plan provider Q&A. You can access this information on our secure provider website through the Quick Links on the right side of the welcome page. The Aetna Medicare Open Plan is a preferred retiree plan option for certain employers. As a result, we anticipate membership growth throughout this year, so you should expect to see more of these members in your office. 4 Aetna OfficeLink Updates June 2007

5 How to streamline Aetna Affordable Health Choices SM administration Aetna Affordable Health Choices are limited benefit plans for hourly and parttime workers, and they function somewhat differently from our full benefits plans. For example, with these plans, there may be a limited number of covered office visits, in addition to out-of-pocket maximum amounts for the member. In addition, these plans have administrative differences that could impact your office. Here are some tips that can help ensure you are paid efficiently and accurately when filing claims for Aetna Affordable Health Choices members. Verify eligibility at every visit You should verify eligibility for Aetna Affordable Health Choices patients at each visit to indicate whether the services provided are covered or if the member has to pay out of pocket. Verify eligibility by calling and providing the member s ID number. You can request a benefits and eligibility fax through our telephone self-service options. Please note that this information is not a guarantee of payment. If you submit claims electronically: Use payer ID when submitting claims electronically. Include the member s ID number on the claim. Using this payer ID automatically routes the claims to SRC for processing and payment. Do not use reference number SRC5555 when submitting claims. This will misdirect your claim and can result in payment delays. The member s ID number is on the front of the card. It will be either the member s Social Security number or a series of numbers beginning with W. If you submit claims on paper: Use payer ID when submitting paper claims. Include the member s ID number on the claim. Mail paper claims to: SRC, an Aetna Company P.O. Box Columbia, SC Do not send paper claims to the El Paso, TX address. This address is for other Aetna claims, not for claims for Aetna Affordable Health Choices which is administered by SRC, an Aetna Company. Sending paper claims to the El Paso address will result in significant payment delays. Because these benefit plans do not require coordination of benefits, if your office is overpaid by an Aetna Affordable Health Choices member, please return any overpayments directly to the member instead of returning money to SRC directly. Questions? To learn more about Aetna Affordable Health Choices, go to our secure provider website and select Doing Business with Aetna, Aetna Benefit Products and Aetna Affordable Health Choices. Aetna to oversee disease management programs Beginning July 1, 2007, Aetna Medicare Advantage plan members will be transitioned to our own Aetna Health Connections SM disease management program from LifeMasters Supported SelfCare Inc. The Aetna Health Connections Disease Management program pairs members identified for the program with an Aetna nurse who serves as their primary point of contact. Each nurse uses an electronic database and a clinical information system to provide broad support for more than 30 chronic conditions. This enables the nurse to offer counseling and assistance not only for the member s primary health issues, but also for other health risk factors that may be associated with the member s condition. To find out if a patient is eligible to participate in the program, call the Member Services telephone number on his/her Aetna ID card. Do not collect copays for post-op follow-ups As a reminder, Aetna s payment for surgical procedures specifically includes payment for follow-up care within the global post-op period. This is true even if a referral for a follow-up is written. Claims will be denied for these visits within the post-operative follow-up period because the claims system will follow global logic of the code. June 2007 Aetna OfficeLink Updates 5

6 Prescription Medications & Pharmacy Management Coverage policy changing for hormone, thyroid compounds Effective October 1, 2007, we will no longer cover the following bioidentical hormones and thyroid compounded drugs: Bi-Est capsule/cream/in oil/troche Bi-Est with progesterone and testosterone capsule/cream Bi-Est with progesterone capsule/cream Bi-Est with testosterone capsule/cream/ troche Estradiol cream/suppository Estriol capsule/cream/suppository Estriol with progesterone and testosterone capsule Estriol with testosterone capsule Estrogen cream/in oil/suppository Estrogen with progesterone and testosterone cream/troche Estrogen with progesterone cream/in oil Estrogen w/testosterone cream/troche Levothyroxine (T4) tab/cap liothyronine cap/tab Progesterone cream (equiv to crinone) hrt Progesterone with testosterone in oil/ capsule/cream/ troche Progesterone hrt cream/capsule Progesterone/DHEA Testosterone capsule/cream/ gel/ in oil/ patch/sl drop/troche testosterone/chrysin Tri-Est capsule/cream/sublingual/troche/ Tri-Est with progesterone and testosterone capsule/troche/cream Tri-Est with progesterone capsule/cream/ troche Tri-Est with testosterone capsule/cream/ troche T3 T3/T4 Tri-Iodothyronine (liothyronine; T3, Levothyroxine T4) More information is available in Medical Clinical Policy Bulletins (CPBs) #0388 and #0608 Complementary and Alternative Medicine and Salivary Hormone Tests, respectively as well as Pharmacy CPB Compounded Drug Products, through our secure provider website. Medical necessity coverage criteria We will consider compounded drug products medically necessary only if all of the following criteria are met: The product contains at least one prescription ingredient. The prescription ingredient is approved by the Food and Drug Administration (FDA) for medical use in the United States. The compounded product is not a copy of a commercially available FDAapproved drug product. The safety and effectiveness of use for the prescribed indication is supported by FDA approval or adequate medical and scientific evidence in the medical literature. Please review the Aetna Preferred Drug List (formulary) at for alternatives covered under your patients specific benefits plans, or talk with them about FDA-approved alternatives. Actiq, Fentora added to precert, quantity limit programs Effective July 1, 2007, Actiq and Fentora will be added to Aetna Pharmacy Management s precertification program for members enrolled in commercial (non-medicare) plans. For plans with the pharmacy precertification program, the following will apply to coverage of Actiq and Fentora: Precertification will be required for members without a cancer diagnosis. Coverage will be limited to managing breakthrough pain in cancer patients. The quantity limit for Actiq will be 15 tablets or lollypops per 30-day supply; the quantity for Fentora will be 15 tablets per 30-day supply. A medical exception is required for coverage for quantities greater than 15 per 30-day supply. Information about alternatives to Actiq and Fentora is available on the Aetna Preferred Drug List (formulary), at To submit a medical exception or precertification request, do one of the following: Fax to Pharmacy Management Precertification at Call Pharmacy Management Precertification at Access our secure provider website, select Pharmacy from the main page, then choose Online Drug Medical Exception/Precertification Request Form. Refer to the April 2007 issue of Aetna OfficeLink Updates for other Pharmacy Management program changes that are effective July 1, Aetna OfficeLink Updates June 2007

7 Physician Focus A MESSAGE FROM TROYEN A. BRENNAN, M.D., CHIEF MEDICAL OFFICER Electronic transactions we all benefit We can agree that our health care system creates a complex business environment for both physicians and payers. One simple solution, which has the added benefit of saving time and money, is greater use of electronic service tools. Every month, millions of people view specific health plan information via the Internet. They use it to research a specific health condition, learn more about various treatment options, and, increasingly, keep track of their health care history with personal health records. We urge the physician community to take similar advantage of the electronic service options available. Our electronic solutions for physicians hold the promise of simplifying business transactions, reducing costs, and improving cash flow. And in the case of e-prescribing, for example, electronic solutions can also improve patient safety. Reducing reliance on paper and telephone calls for insurance administration can save both physicians and insurers time and money. According to some estimates, a physician who currently relies on paper and telephone calls for insurance administration could save up to $40,000 a year simply by increasing electronic transactions for operations such as claims submission, referral and preauthorization requests, and eligibility verification. Our electronic solutions continue to evolve to meet your needs in large part based on valuable feedback we have received from physicians and office professionals. Ongoing enhancements to Aetna s secure provider website are good examples. We were the first health plan to offer online access to clinical policy bulletins. Because of your input, we implemented Clear Claim Connection, which enables physicians to look up service codes and better understand how we process claims. Today, health care professionals also can access an enhanced set of real-time transactions, all at no cost. In addition to clinical policies and claims logic, key site features include: Submitting claims, referral inquiries and checking claim status Verifying patient eligibility Enrolling in ERA/EFT Most recently, we are promoting consistent electronic information exchange among health plans and others in the health care industry through our work with the CAQH Committee on Operating Rules (CORE). CORE builds on existing standards, such as HIPAA, to make electronic transactions more predictable and consistent, regardless of the technology, simplifying the member eligibility verification process. So why use technology to do business with Aetna? Quite simply: to save time and money. Take a few minutes today to tour our secure provider website at If you ve never been out there, Aetna offers resources that can help your organization become familiar with and use these electronic service options. And to those of you who use the site consistently, thank you. Troy Reducing reliance on paper and telephone calls for insurance administration can save both physicians and insurers time and money. Sincerely, Troyen A. Brennan, M.D. Senior Vice President and Chief Medical Officer June 2007 Aetna OfficeLink Updates 7

8 OfficeWise Submit electronic transactions via new direct-connect option Precertification list updates available online You now have another web-based option for submitting electronic transactions to us, and there s no third party involved. In addition to our secure provider website, providers, billing companies and vendors now can submit their electronic transactions directly to us via a new website Aetna EDI Connect SM ( Aetna EDI Connect lets you submit all your electronic transactions to us free of charge. It simplifies the process by enabling you to submit a single file containing all your electronic data interchange (EDI) files in one easy transaction. Aetna EDI Connect is easy to use Before you can begin submitting transactions through this new website, please register at After enrolling, you will receive an with your new ID and password. Following a short test period to verify that your electronic transmissions are being correctly submitted and received, you will receive full access to the site. We re here to help For more information about this easy-to-use website, please contact your state s Aetna Office Solutions representative. The following electronic transactions are available through Aetna EDI Connect: Real-time eligibility Claim status inquiry Unsolicited claim status Medical precertification inquiry Medical referral inquiry Medical precertification request/response Medical referral request/response Electronic remittance advice (ERA) Claims submission Coordination of benefits (COB) We ve updated our 2007 precertification list to include new information about region-specific managed service organizations responsible for precertifying certain services, as well as market-specific precertification requirements. As a reminder, effective May 1, 2007, precertification is required for high-tech radiology procedures for HMO-based plan members in additional markets and for PPO-based plan members in most markets. These changes are also reflected on the updated precertification list. To view the list, go to the Aetna website. Select for Health Care Professionals, Services and Tools, then Medical Resources. You can also use our Precertification Code Search Tool to find out if a specific code needs precertification. Simply enter a valid five-digit code and get precertification requirements for that procedure. Options to reach us Go to Select for Health Care Professionals E-claims can be used for all benefits plans You not your patients benefits plans determine if you submit claims electronically. Start saving time and money today by using e-claims! If you are not already submitting e-claims, simply register with our secure provider website. Then, it s up to you whether you want to submit claims free of charge through our secure provider website, or use one of our directly connected claims submission clearinghouses. That s all there is to it. Select Physician Self-Service and Log In Or call our Provider Service Center For indemnity and PPO-based benefits plans call MDAetna ( ) For HMO-based benefits plans call Aetna OfficeLink Updates June 2007

9 What s new on our secure provider website We re continually refreshing our secure provider website to give you access to the latest tools and resources for doing business with us. In addition to updating the functionality of some transactions, we recently updated the site content highlighted below: Claims Added new CMS 1500 online claims submission form, including recent CMS changes and fields for entering your National Provider Identifier (NPI) Doing Business with Aetna New page for Aetna Medicare Open SM Plan (PFFS) resources Updated Health Care Professional Toolkit Updated information on our Physician Advisory Board New page for Aetna Behavioral Health resources Clinical Resources Added Nephropathy Screening Physician Toolkit Added Antibiotic Treatment Physician Toolkit Added new Quit Tobacco Program information Updated various Clinical Practice Guidelines Education Added video tour of Aetna s Education Site for Health Care Professionals Added new courses: Diversity in Health Care; Aetna Medicare Open Plan; Changing Health Care Marketplace Update Profiles Created new link to add/update NPI, as well as added overview and help documents Forms Library Updated and added new Precertification Additional Information Request Forms Updated ERA/EFT Enrollment Form Members may have to pay for lab tests considered experimental or investigational Recently, we ve heard from some members who unexpectedly had to pay for lab tests that they thought were covered services. Although these tests were ordered by their physician, the procedures were not covered because Aetna considered them experimental or investigational under the terms of the member s health plan. As a reminder, Aetna s plans do not cover laboratory tests that are considered experimental or investigational, even when ordered by a physician. The chart below lists some lab tests commonly ordered on behalf of Aetna members that Aetna considers to be experimental or investigational. Because these tests are not covered, Aetna will reject claims submitted for these procedures and the member will be financially responsible for those services. If you do order these tests for your patients, you should inform them of Aetna s position and tell them that they will be responsible for payment of these tests. If you have questions about these procedures, please refer to the corresponding Aetna Clinical Policy Bulletin. How to verify if a lab test is covered An online reference tool listing laboratory tests that are excluded from coverage or may be conditionally covered is available to you. This is found on our secure provider website by going to the Claims page, choosing CPT/HCPC Coding Tools, then Clinical Policy Code Lookup under Step 1. Then, use the Select a code by category drop-down menu. Lab Test Homocysteine (83090) 0381, 0562 Lipoprotein (A) (83695) 0381 Immunoassay for tumor antigen, 0352 quantitative CA 19-9 (86301) Infectious agent detection by 0443 nucleic acid (DNA or RNA); Papillomavirus, human, amplified probe technique (87621) Aetna Clinical Policy Bulletins June 2007 Aetna OfficeLink Updates 9

10 Striving for Quality Excellence Keeping you informed: NCQA-required notification The National Committee for Quality Assurance (NCQA) requires health plans to regularly inform physicians of the availability of Preventive Services and Clinical Practice Guidelines. These guidelines are based on nationally recognized recommendations and peer-reviewed medical literature, and are posted on our secure provider website for your reference. Once logged in, select Clinical Resources. Preventive Service Guidelines (reviewed/updated 3/07) Clinical Practice Guidelines: Asthma Treating Patients With Asthma (last reviewed 1/06) Behavioral Health Clinical Practice Guideline: Antidepressant Prescribing Guide for Use in Primary Care (reviewed/updated 1/06) Helping Patients Who Drink Too Much (adopted 5/06) Treating Patients With Bipolar Disorder (adopted 5/06) Treating Patients With Major Depressive Disorder (adopted 5/06) Depression Component of Clinical Practice Guideline for Diabetes (adopted 3/07) Diabetes Treating Patients With Diabetes (adopted 3/07) Heart Disease Treating Patients With Chronic Heart Failure (adopted 1/06) Treating Patients With Coronary Artery Disease (adopted 11/06) Treating Patients With Hypercholesterolemia (adopted 5/06) Treating Patients With Hypertension (last reviewed 5/06) For a hard copy of our Preventive Services Guidelines or a specific Clinical Practice Guideline, please contact our Provider Service Center at MDAetna. Coverage determinations: what you need to know When Aetna makes a coverage decision for a patient: We use evidence-based clinical guidelines from nationally recognized authorities to guide utilization management (UM) decision making. Decisions are made based on the appropriateness of care and the existence of coverage for the service. We do not use incentives to reduce utilization or hinder access to care. Specifically, we review any request for coverage to determine if the member is eligible for benefits, if the service requested is a covered benefit under the member s plan, and if the service is delivered consistent with established guidelines. If a request for coverage is denied, the member (or a physician acting on the member s behalf) may appeal this decision through the complaint and appeal process. In addition, staff conducting UM activities assist members in accessing the services covered under the plan. We do not reward physicians or individuals who conduct utilization review for creating barriers to care or for issuing denials of coverage. You can find more information on our utilization review policies on the Aetna website. Select for Health Care Professionals, Clinical Policy Bulletins then Utilization Review Policies. 10 Aetna OfficeLink Updates June 2007

11 North Central News Changes to national laboratory agreements Effective July 1, 2007, there will be two important changes to our national laboratory agreements. Laboratory Corporation of America (LabCorp) and its affiliates will no longer participate in the Aetna network. We have a new preferred, national agreement with Quest Diagnostics for members in all Aetna benefits plans. Quest offers these advantages Quest Diagnostics has more than 2,000 Patient Service Centers nationwide. Over the coming months, we will be adding additional Quest Diagnostics locations. We will also continue to contract with various local and specialty laboratories. Quest Diagnostics also offers Care360, a physician portal through which you can transmit lab orders and receive results electronically. You can learn more about Care360 by contacting your local Quest Diagnostics representative. Use DocFind to locate a participating lab Please continue to refer all Aetna patients to participating laboratories to help minimize their out-of-pocket costs. For a list of participating labs in your area, including Quest Diagnostics locations, visit DocFind, our online provider directory, at COLORADO, INDIANA, ILLINOIS, MICHIGAN, MISSOURI, WISCONSIN Aexcel and health care transparency expand to additional locations Aexcel is a designation within Aetna s performance network that will be introduced in Colorado and Kansas City in January It includes physicians in 12 specialties who have demonstrated effectiveness in the delivery of care based on a balance of clinical performance and efficiency measures. We will notify specialist physicians in the Aexcel specialties of their Aexcel designation status in mid-summer. Those who meet the Aexcel selection criteria will be Aexceldesignated physicians; those who do not are considered Aexcel non-designated physicians. Although non-designated physicians remain part of the broad Aetna network, access to these providers is determined by a member s benefits plan. In preparation for the 2008 Aexcel roll-out, we will update our secure member website in August to reflect information on Colorado and Kansas City specialists. A symbol next to a specialist s name followed by a 1/1/08 effective date indicates when the specialist s Aexcel designation begins. Members can also see details on the physician s performance and which Aexcel standards (volume, clinical performance measures and efficiency) were met. This information is available for both Aexceldesignated and non-designated physicians. June 2007 Aetna OfficeLink Updates Aexcel promotes access to independent, objective information about physicians to aid members in selecting specialists and to help mitigate increases in medical costs. Aexcel specialties: Cardiology, Cardiothoracic surgery, Gastroenterology, General surgery, Neurology, Neurosurgery, Obstetrics/gynecology, Orthopedics, Otolaryngology, Plastic surgery, Urology, Vascular surgery Physician-specific cost, clinical performance and efficiency information available to members As mentioned in the April 2007 issue, we are also expanding our health care transparency initiatives to additional areas including the North Central Region to help our members make more informed decisions about their health care. Health care transparency means members have online access to physician-specific cost, clinical performance and efficiency information. In August, unit price transparency (physician-specific cost information only) will be introduced in Milwaukee. Health care transparency will be introduced in the following areas: Indianapolis Chicago Detroit Colorado Kansas City At that time, we will update our secure member website to reflect physician-specific information. Members will be able to view participating physicians actual rates specific to the member s health plan for up to 30 of the most widely accessed services. This includes office visits, diagnostic tests, and major and minor procedures performed by primary care and specialty physicians. Members interested in clinical performance and efficiency can see whether the specialty physician is Aexcel designated. If the physician managed a minimum number of Aetna member cases, information on the physician s clinical performance and efficiency in use of medical services is included. Additional information is available online You ll find additional information on health care transparency, Aexcel and the selection criteria, on our secure provider website. Once logged in, select Aetna Health Care Transparency Initiatives on the right-hand menu bar. We ve also developed an Aexcel Office Administration course on the Education Site for Health Care Professionals. Once on the Education home page of our secure provider website, click Enter to go the Education site and select the Course Catalog to find courses. 11

12 CPE RS Farmington Ave. Hartford, CT Contact us at: Please route this publication to: Office Manager Business Staff Front Desk Staff Medical Records/Medical Assistants Primary Care Physicians Specialists Physician Assistants/Clinical Nurse Specialists Nurses Referral and Precertification Stafftaff Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefit coverage include Aetna Health Inc., Aetna Life Insurance Company and Corporate Health Insurance Company and Strategic Resource Company. CMS implements National Provider Identifier contingency plan The Centers for Medicare & Medicaid Services (CMS) has implemented a contingency plan for covered entities that did not meet HIPAA s May 23, 2007 deadline for obtaining a National Provider Identifier (NPI). The guidance issued by CMS clarifies that, for 12 months after the compliance date, (that is through May 23, 2008), CMS will not enforce penalties against covered entities that deploy contingency plans to help ensure the smooth flow of claims payments. CMS will follow this approach to enforcement, provided that the covered entities can demonstrate that they have made good faith efforts to become compliant and, in the case of health plans, to facilitate the compliance of their trading partners. While Aetna is fully able to support NPIs in HIPAA transactions, we recognize that more time is needed to allow for the sharing and testing of NPIs in transactions between covered entities. Therefore, consistent with CMS guidance, we will accept transactions that include other legacy provider identifiers until May 23, If you have not yet obtained an NPI, you should do so immediately. We then ask that you follow the steps under Sharing Your NPI With Aetna, located on the Aetna website under for Health Care Professionals. It is important to begin using your NPIs in HIPAA standard electronic transactions as soon as possible. You ll find additional information on the CMS announcement at The information and/or programs described in this newsletter may not necessarily apply to all services in this region. Please contact your Aetna network representative to find out what is available in your local network. Application of copayments and/or coinsurance may vary by plan design. This newsletter is provided solely for your information and is not intended as legal advice. If you have any questions concerning the application or interpretation of any law mentioned in this newsletter, please contact your attorney NC (6/07) 2007 Aetna Inc.