New Jersey Providers

Aetna/ Triad Claims Submission Instructions

For claims for services rendered before April 1, 2013, click here

For claims for services rendered from April 1, 2013 to present:

The following information provides an overview of where to submit your Aetna New Jersey chiropractic claims.

“Provider Classes” based on network participation status and affirmative agreement to plan participation:

1. Aetna/Triad Par HMO only – This includes Health Network Option/Only and Medicare Advantage plans
2. Aetna Par only
3. Non Participating with Aetna

“Member Classes” based on Aetna plan participation and plan inclusion in Aetna/Triad arrangement.

1. HMO including Medicare
2. PPO
3. Excluded Aetna NJ plans (Flexible Spending Accounts FSA, Health Savings Accounts HSA, Aetna Workers’ Comp Access, Cofinity, Strategic Resource Company, Aetna Signature Administrators)
4. HMO Excluded Plan Sponsors (see HMO-based, Health Network Option/Only, Medicare Advantage products Excluded Plan Sponsors  (PDF, 26 KB). These groups are excluded from claims processing by Triad.

Note:  the member’s plan determines whether a claim is a covered charge.  If a member’s plan does not include out-of-network benefits, then coverage may not be provided.

Claim addresses:

Aetna:  Submit claims to Aetna at the address listed on the back of the member’s ID card.

Triad HealthCare:  Paper claims may be submitted to Triad HealthCare at:

80 Spring Lane
Plainville, CT 06062
 
Electronic submissions may be submitted to Triad HealthCare as follows: 
Triad HealthCare partnered with MD On-Line for electronic claim submission. Providers may enter these individually, free of charge. To access this benefit, log-in to Triad HealthCare’s website at http://www.Triadhealthcareinc.com/providers/onsolution.aspx and click the Submit button under Online Solutions. 

This routes you to MD On-Line’s portal for Triad HealthCare Providers. Include Triad HealthCare’s address and electronic payer ID 39181. To learn more about MD On-Line’s products for submitting Triad HealthCare claims electronically free of charge, call Triad HealthCare at 1-800-409-9081.

Network participation:

Under this arrangement chiropractors are either contracted with Triad HealthCare or not contracted with Triad HealthCare for HMO-based, Health Network Option/Only and Medicare Advantage plans. All Triad HealthCare participating providers are required to sign an addendum to the Triad HealthCare Aetna Participating Provider Agreement.

Aetna plans to non-renew agreements with chiropractors who are currently participating with Aetna for HMO-based, Health Network Option/Only and Medicare Advantage plans, but who have decided not to join the Triad HealthCare network for HMO-based, Health Network Option/Only and Medicare Advantage plans. The effective date of non-renewal by Aetna will be based on the provider’s contract with Aetna. This will begin with second quarter, 2013 contract renewals. Aetna will provide providers with 90 days prior written notice of the non-renewal.

If you elect to not participate with Triad HealthCare you may still see Aetna patients.  However, coverage will only be provided if the member’s plan includes out-of-network benefits.  The member will be responsible for the out-of-network cost-sharing for these services.

Note:  If you currently have an agreement with Aetna for the following excluded plans, that Aetna agreement continues to be in place for the excluded plans:
• High Deductible Health Plans (HDHP) – HMO-based products
• HMO90
• HSA – HMO-based plans
• HRA – HMO-based plans

Continue to submit claims to Aetna for Aetna Workers’ Comp Access^®, Cofinity^®, Strategic Resource Company^® Aetna Signature Administrators^® plans, which Triad never managed.

Utilization management:

Triad HealthCare:  There will be no utilization review for a member’s first 10 visits of therapeutic care. This will apply to HMO-based, Health Network Option/Only and Medicare Advantage plans administered by Triad HealthCare. Preventive medicine and established patient evaluation/management services will be reviewed for medical necessity. Triad HealthCare will continue to review claims for services not covered by Aetna’s benefits plans.  This includes maintenance care and scheduled supportive care. For treatment plans extending beyond 10 visits, participating providers may elect to prior authorize the 11th and subsequent visits.  Or you may provide care and Triad HealthCare may review the 11th and subsequent visits retrospectively.

The 10 visit threshold is not a calendar year benefit and does not reset on January 1st of each year.

For a complete list of Triad HealthCare’s medical policies, access Triad HealthCare’s website at http://www.Triadhealthcareinc.com/providers/policies.aspx.

All existing chiropractic referral requirements still apply.

Note:  Some Aetna plan sponsors have elected to not participate in Triad HealthCare’s Utilization Management (UM) program. See attached.

Certain HMO-based, Health Network Option/Only or Medicare Advantage plans, Aetna plan sponsors can be excluded from Triad Healthcare’s utilization management and claims processing program.  Claims for plan sponsors who have been excluded for HMO-based, Health Network Option/Only or Medicare Advantage plans should be sent to Aetna. Aetna’s medical review guidelines still apply to self-funded plans and the provider does need to follow Aetna’s standard Clinical Claim Review referral guidelines.

Claims for plan sponsors who have excluded from Triad for HMO-based, Health Network Option/Only or Medicare Advantage plans for utilization management and Claims Processing should be sent to Aetna: 

• HMO-based, Health Network Option/Only, Medicare Advantage products Excluded Plan Sponsors  (PDF, 26 KB)

Certain HMO-based, Health Network Option/Only or Medicare Advantage Aetna plan sponsors have implemented a utilization management program that is specific to their enrollees.  Providers should be aware of the visit threshold exceptions for these plan sponsors so they know when utilization management will occur.

Claims for these HMO-based, Health Network Option/Only or Medicare Advantage plan sponsors with a visit threshold exception should be submitted to Triad Healthcare.

• Plan Sponsor Exceptions - HMO-based, Health Network Option/Only or Medicare Advantage  (PDF, 12 KB)

Beginning November 1, 2012, Aetna discontinued medical necessity reviews for fully insured plans that it directly administers. This applies to any new physical therapy, occupational therapy and chiropractic services. Any plan limits will still apply. For members in self-funded plans that Aetna directly administers, it manages the medical necessity review after the member’s 25th visit for each episode of care. Some plans may have a different visit limit, so check the member’s benefits.

Note: This change in medical necessity review applies to plans that Aetna manages. The policy that Aetna began on November 1, 2012 doesn’t impact the plans that Triad manages. Fully insured HMO-based plans will still have a medical necessity review that Triad performs.

Point of Service Plans

Aetna has three Point of Service products:

1. Quality Point of Service (QPOS^®) Plan- This plan is either an HNO or HMO-based plan
2. Aetna Choice^® POS Plan – This is an HMO-based plan
3. Aetna Choice^™ POS II – This is a PPO-based plan