Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy | Dispute Process

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Medical - Payment Policy

• Billing Policies and Processes
• Change in Reimbursement Policy for Non Par Behavioral Health Providers
• Physician External Review
• Provider Procedures for Submitting Refunds
• Submission of Clinical Records

State Specific

Arizona

• Health Care Provider Rights - Timely Pay   (2 pages)
• Timely Pay and Grievance Law - Regulatory Bulletin 2006-02   (13 pages)

California

Complaint & Appeal Procedures:
California HMO - Practitioner/Provider Dispute Resolution Policy   (6 pages)


New Jersey

• New Jersey Provider Appeal Procedure  (1 page)
• New Jersey Department of Banking and Insurance Health Care Provider Application to Appeal a Claim Determination   (2 pages)
• Extension of Benefits
  
  A subscriber or dependent may be eligible for continued coverage under the Aetna benefits plan if the subscriber's plan would otherwise terminate but the plan includes a provision for continued coverage for total disability and the subscriber or dependent initiates a request for continued coverage by contacting Aetna Member Services.
  
  The individual who is totally disabled must meet the extension eligibility requirements on the date that coverage would otherwise end.
  
  If the request for continued coverage is approved, the continued coverage applies only to the individual who is disabled and not to other family members. In addition, the terms of coverage at the time of the approved extension remain in effect and the continued coverage would be subject to all plan provisions and limitations.
  
  The following forms must be completed and submitted to Aetna Member Services for consideration. Contact Aetna Member Services using the phone number listed on back of the Aetna Member ID card to obtain the mailing address.
  • Request for Continued Coverage due to Extension of Benefits for Total Disability Form ? An attending physician statement from the treating practitioner(s) supporting the request.  (3 pages)
  • Handicapped Child Attending Physician's Statement/Behavioral Health Attending Physician's Statement for behavioral health conditions (all ages) and medical conditions for dependents age 18 and younger.  (2 pages)
  • Adult Medical Attending Physician Statement for medical conditions for subscribers and dependents over the age of 18.  (4 pages)


• Present on Admission Indicator Code
  
  Effective 10/1/2008, Present on Admission (POA) indicator codes will be required for determining appropriate DRG (Diagnosis Related Grouping) assignment and thus pricing. The code is required for both Commercial and Medicare lines of business. A POA code is a code used to indicate if the corresponding diagnosis was present at the time of admission. A POA code is required for all primary and secondary diagnosis codes; however a POA code is not needed for the admitting diagnosis code. Refer to the below for a list of POA indicator codes.
  
  Value in the POA Field Meaning
  
  Y     Diagnosis was present at the time of inpatient admission.
  
  N     Diagnosis was not present at the time of the inpatient admission.
  
  U     Documentation insufficient to determine if condition was present at the time of inpatient admission.
  
  W     Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of the inpatient admission.
  
  1 or Spaces Unreported/not used. Exempt from POA reporting.
  
  

Texas

Aetna Clean Claim Disclosure Forms for Texas-Based Physicians and Health Care Professio

Members:
http://www.aetna.com/members/member_services.html