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New Jersey Providers

 

Chiropractic Services: Precertification and Claims Processing

Aetna has delegated to a third party vendor responsibility for Pre-certification and/or Claims Processing of chiropractic services, under our HMO and Medicare (except for Medicare Fee For Service) products.  

Please Note: Except as otherwise indicated, whether the vendor is responsible for pre-cert, and whether the claim should be sent to the vendor or to Aetna, is determined by the location of the Primary Care Physician’s (PCP’s) office; if the Member does not have a PCP, it is determined by the Member’s residence.  

PCP’s office, or if there is no PCP the Member’s residence, located in a county in Northern New Jersey (Bergen, Essex, Hudson,  Hunterdon,  Middlesex,  Monmouth, Morris,  Ocean Passaic,  Somerset,  Sussex, Union, or Warren) ….

Precertification

Contact Triad HealthCare for precertification HMO and Medicare

Note: Some Plan Sponsors have elected not to participate  (PDF, 28 KB) in Triad HealthCare’s   precertification program.

Claim Submission

Submit to Aetna:

  • All claims for services of providers not contracted with Triad or Aetna
  • All claims under PPO plans
  • All claims under High Deductible Health Plans, including but not limited to HDNPs that are part of an FSA or HSA.
  • All claims of Members whose Plan Sponsor has elected not to participate  (PDF, 28 KB) in Triad HealthCare’s precertification program.

Submit to Triad Healthcare:

  • HMO claims where the provider is contracted with Triad HealthCare and the member’s claim is not on the “Submit to Aetna” list above

PCP’s office, or if there is no PCP the Member’s residence, located in a county in Southern New Jersey (Atlantic, Burlington, Camden, Cape May, Cumberland,   Gloucester, Mercer, or Salem) ….

Precertification

No precertification required

Claim Submission

Submit all claims to Aetna

Contact Information

Triad Healthcare
Phone: 1-800-409-9081
Fax: 1-866-225-1033
Website: www.triadhealthcareinc.com

New Jersey Claim Form - “Health Care Application to Appeal a Claims Determination”

Aetna: http://www.aetna.com/provider/data/NJ_prov_appeal_proc.pdf  (PDF, 21 KB)

Triad: http://www.triadhealthcareinc.com/providers/pdfs/NJ_HC_Provider_Application_to_Appeal_a_Claim_Determination.pdf  (PDF, 127 KB)