New Jersey Providers

Physical and Occupational Therapy Services: Precertification and Claims Processing

Aetna has delegated to a third party vendor responsibility for Pre-certification and/or Claims Processing of physical and occupational therapy 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 OrthoNet Inc. for precertification HMO and Medicare
     
Note: Some Plan Sponsors have elected not to participate  (PDF, 25 KB) in Orthonet’s  precertification program.

Claim Submission

Submit to Aetna:

• All claims for services of providers not contracted with Orthonet or Aetna
• All claims for hospital-based services
• 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, 25 KB) in Orthonet’s precertification program.

Submit to Orthonet:

• HMO claims where the provider is contracted with Orthonet 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

Orthonet Inc.
Phone: 1-800-771-3205
Fax: 1-800-771-4310
Website:  www.orthonet-online.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)

Orthonet: http://www.orthonet-online.com/dl_aetna.html