Effective December 1, 2020, we will be reactivating edits for billing modifiers 25, 59 and X series in New Jersey for fully insured and self-insured membership claims. We may request medical records for these services as provided to your New Jersey fully insured* patient claims.
The medical records review program will not apply to self-insured membership claims. These new edits are part of our Third Party Claim and Code Review Program and will apply prior to finalizing claims for professional services and outpatient facilities.
We may request medical records for professional services provided to New Jersey fully insured* patients and billed with modifiers 25, 59 and X series. This is not a clinical review; any edit applied will be based on industry-recognized coding guidelines. We will review the service, service history, changes in condition, diagnostic tests and the medical chart to determine if these services require separate payment. We allow charges for covered services not subject to the coding review.
We want you to know the following:
- You can send medical records with your initial claim submissions for services provided to New Jersey fully insured* patients.
- If medical records are not provided and needed, Aetna® will request them.
- If a medical chart is requested but not submitted within 45 days, then the charges for the service billed with modifiers 25, 59 or X series will be denied.
Keep in mind the following:
- We follow both New Jersey claims processing timelines, and appeal rights apply to any denied charges.
- You can submit medical records/notes via the following:
- Fax number or address on the EOB
- The “Claim Status — Send Attachments” functionality through our provider portal on Availity®
- This program applies to certain claims for charges $25 or greater and billed with modifiers 25, 59 or X series.
To find out if our new claims edits will apply to your claim, log in to the provider website. Then go to Plan Central > Aetna Claims Policy Information > Policy Information > Medical Records Program.
*New Jersey member ID cards indicate whether the member is covered under a fully insured plan or under a self-funded plan.