UPDATE: Aetna Prior Auth Requirement for DCs in PA, NY, DE and WV effective September 1, 2018--Policy Applies Only to Certain Aetna Plans!
WE HAVE AN UPDATE TO THE BELOW NOTICE. One of our clients was kind enough to share with us information about this new policy.
- First, the new policy only applies to patients who have Medicare Advantage plans OR Full Insured plans.
- Second, you must call Aetna on EVERY patient to determine if the patient has a Medicare Advantage or Full Insured Plan so you know if prior authorization is needed. You cannot determine this information from the patient's card or online (you should be able to determine if it is a Medicare Advantage plan from the card!).
- If Aetna says it is NOT a Medicare Advantage or Full Insured Plan, it is best to just confirm on the phone that prior authorization is not needed.
- So the below policy would only apply if the patient has a Medicare Advantage or Full Insured plan.
This notice is only for our chiropractic clients in PA, NY, DE and WV. This is a reminder that as of September 1, 2018 ALL chiropractic services for Aetna and Coventry patients must be pre-authorized. You can review the information at: https://www1.radmd.com/all-health-plans/aetna.aspx.
A few things to keep in mind:
- It is your responsibility to ensure you have obtained prior authorization prior to seeing an Aetna or Coventry patient.
- It is strongly suggested that you have the patient sign essentially what is an Advance Beneficiary Notice in which the patient indicates that he/she will be responsible for the charges if Aetna denies prior authorization.
- YOU SHOULD NOT SUBMIT ANY BILLING FOR AN AETNA PATIENT WITHOUT FIRST OBTAINING PRIOR AUTHORIZATION. IF YOU SUBMIT BILLING TO US, WE WILL ASSUME THAT YOU HAVE OBTAINED PRIOR AUTHORIZATION AND WE WILL SUBMIT THE CLAIM TO AETNA.
- If we do submit the claim to Aetna and they deny because of no prior authorization, at that time the charges must be written off. You CANNOT then collect anything from the patient, even if the patient signed an agreement prior to the services being rendered. That's why it is best to NOT submit billing for an Aetna patient until you have received the decision from Aetna as to the prior authorization. If you do NOT submit a visit for that date and Aetna denies the prior authorization request BUT you have had the patient sign an agreement, then you will not bill Aetna for that visit but instead consider the patient a cash patient.
- It is also strongly suggested that you contact your state Chiropractic Association about this new practice. I know the Pennsylvania Chiropractic Association is looking into this new policy and they are urging their members to contact them regarding any issues that may arise with Aetna.