New Jersey providers

Radiology and other outpatient imaging services: Precertification and claims processing

Aetna has delegated responsibility for pre-certification and/or claims processing of certain radiology, imaging and related services to a third party vendor. This is for our HMO-based, Health Network Option and Health Network Only, collectively referred to as Aetna Health Network, PPO-based and Medicare Advantage (except for Medicare fee-for-service) plans.

Note: Except as otherwise noted, whether the vendor is responsible for precertification, and whether the claim should be sent to the vendor or 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 where the member lives.

CareCore is Aetna's third-party vendor for Northern New Jersey.   Northern New Jersey includes Bergen, Essex, Hudson, Hunterdon, Middlesex, Monmouth, Morris, Ocean Passaic, Somerset, Sussex, Union and Warren counties.

Precertification 

Pre-approval from CareCore National (CCN) is required for the following services: 

• Outpatient imaging
• Sleep studies
• Cardiac imaging
• Cardiac implants
• Radiation oncology

Note: Some plan sponsors have elected not to participate in CCN’s program. Aetna HMO-based, PPO-based, Aetna Health Network and Medicare Advantage plan sponsors can be excluded from CCN's utilization management and claims processing program.  PPO-based plan sponsors have to opt into CCN's programs, so there is not a list of PPO-based plan sponsors who are excluded.

Check eligibility for PPO-based members.  Excluded plan sponsors for Aetna HMO-based, Aetna Health Network and Medicare Advantage plans can be found here  (PDF, 19KB).  Providers do not need to contact CCN for utilization management for members who are part of a plan sponsor excluded from CCN. Providers should send claims for plan sponsors who have been excluded directly to Aetna.  Aetna medical review guidelines will apply for all claims submitted to us. Providers must follow our standard Clinical Claim Review referral guidelines.

Claim Submission 

Send to Aetna:

• All claims for services from providers not contracted with either CCN or Aetna.
• All claims for services for members who live in a Southern New Jersey county.
• All claims for imaging services provided as part of an inpatient stay, in a hospital emergency department, part of an ambulatory surgery procedure, or performed at an urgent care center.
• All claims under PPO plans.
• All claims under high-deductible health plans (HDHPs), including but not limited to HDHPs that are part of a flexible spending account (FSA) or health savings account (HSA).
• All member claims for excluded plan sponsors  (PDF, 19 KB) who are not included in CCN's precertification program.

Send to CCN:

• HMO-based, Health Network Option and Health Network Only, collectively referred to as Aetna Health Network and Medicare Advantage claims where the provider is contracted with CCN, and the member’s claim is not on the “Send to Aetna” list above.
• HMO-based, Health Network Option and Health Network Only, collectively referred to as Aetna Health Network and Medicare Advantage claims falling within the 70,000 series. This excludes radiation oncology, therapeutic nuclear medicine, ophthalmic ultrasounds and preadmission test codes.

MedSolutions is Aetna's third-party vendor for Southern New Jersey. Southern New Jersey includes Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer and Salem counties.

Precertification

Pre-approval from MedSolutions is required for the following services:

• High-tech radiology
• Sleep studies
• Cardiac imaging
• Cardiac implants

Note: Some plan sponsors have chosen not to participate in the MedSolutions program. Aetna HMO-based, PPO-based, Aetna Health Network and Medicare Advantage plan sponsors can be excluded from the MedSolutions utilization management program. Med Solutions does not process claims for Aetna. PPO-based plan sponsors have to opt into the MedSolutions program, so there is not a list of PPO-based plan sponsors who are excluded. 

Check eligibility for PPO-based members. Excluded plan sponsors for Aetna HMO-based, Aetna Health Network and Medicare Advantage plans can be found here  (PDF, 19 KB). Providers do not need to call MedSolutions for utilization management for members who are part of a plan sponsor excluded from the MedSolutions program. Send all claims to Aetna. Aetna's medical review guidelines still apply, and the provider must follow Aetna's standard Clinical Claim Review referral guidelines.

Claim Submission 

• Send all claims to Aetna

Contact Information

CareCore National
Phone: 1-888-622-7329
Fax: 1-800-540-2406
Fax: 1-888-444-1562 (sleep studies only)
Website: www.carecorenational.com

MedSolutions
Phone: 1-888-693-3211
Fax: 1-888-693-3210
Website: www.medsolutionsonline.com

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

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

CareCore: CareCore Policies & Payment Rules