• Physical Therapy and Occupational Therapy - Provided through Doral Therapy Services @ (888) 560-6855
• All Psych except Neuro Psych is carved out.
• Select Pathology
• Select Radiology - See the MedSolutions Precertification List for excluded services. 

**For further clarification of "All MCO Credentialed Faculty" refer to the Table of Contents.

• LabCorp (Effective February 1, 2003) - PCP's for Family Practice and Internal Medicine are excluded from LabCorp.
• Quest Diagnostic -  Preferred Provider

See attached list of STAT Labs that will be reimbursed when performed in the PCP's office.

See the attached  list of STAT Labs that will be reimbursed when performed in a Specialist's office.

• Algur H. Meadows Diagnostic Imaging Center
• Aston Radiology (Not all services excluded)
• Mary Nell & Ralph B. Rogers MRI Center
• PET Imaging Facility

Effective August 1, 2003, our facilities are included in as Preferred Radiology Facilities with MedSolutions.

See attached list of Radiology Procedures that will be reimbursed when performed in the PCP's office.

See the attached list of Radiology Procedures that will be reimbursed when performed in a Specialist's office.

Note:
For procedures that may not be performed in the office and that require precertification, please refer to the MedSolutions Precertification List. The toll free fax number for submission of precertification requests is (888) 693-3210.

• Children’s Medical Center
• Parkland Health & Hospital System
• St. Paul Medical Center
• Zale Lipshy University Hospital
• UT Southwestern Clinical Procedure Center (ASC)
• Moncrief Radiation Oncology Center (MROC)

• For plans with a PCP option, members must comply with the referral requirements listed below for the highest level of benefits.
  
  
• To access the Aetna's VRU, call (800) 624-0756. See the attached Aetna Help Sheet for additional information.
  
  
• Referrals can be entered for a specific provider by using the provider's Aetna PIN or for a certain specialty using the Taxonomy Codes .  If the referral is entered using the Taxonomy Codes , any participating Aetna physician with that specialty can see the patient.
  
  
• PCPs may use CPT code 99499 (unlisted evaluation and management service), which allows specialists to be reimbursed for any covered procedures (except laboratory and radiology procedures) performed in an office setting. Those laboratory and radiology procedures that specialists currently are allowed to perform in their offices will continue to be recognized.  Additional laboratory and radiology procedures, listed on the "Consult and Treat Information Sheet", will also be allowed.
  
  
• Automatic Studies are services which may be performed in the specialist's office when patients are seen for visits and evaluations as a result of the direct access program even if the procedure itself was not specifically indicated on the referral. Please refer to the Aetna Automatic Studies List for procedures that fall within this direct access program.
  
  
• Referrals are valid for 30 days or for the number of visits indicated on referral form. After this time period it would be necessary for the generation of another referral. (See the  Aetna Help Sheet for more information.)
  

• Aetna members have open access to participating obstetricians and gynecologists. The OB/GYN can refer the member for the following tests and specialty care related to gynecological problems without the need of having the member return to her PCP for a referral:

1. Pelvic Ultrasounds and Breast Ultrasounds
2. Mammograms-Gynecologic Oncologists
3. DEXA scans-Urologists
4. Surgeons for Breast problems

For information on Aetna Transplant members,
please refer to Aetna National Medical
ExcellenceTransplant Network.

• Medical Precertification:  VRU - (800) 624-0756. See the Aetna Help Sheet or fax the Aetna Precertification Fax Form  to (800) 443-1884.
• Maternity Management Program:  (800) 272-3531
• Pharmacy Precertification:  (800) 414-2386
  For non-covered medications, please fax a Drug Exception Precertification Form to 800-408-2386.

Precertification is required for certain outpatient, elective, high technological imaging procedures including, CTs, MRI/MRAs, PET Scans, and Nuclear Cardiac Imaging Studies from MedSolutions. The authorization number obtained will be valid for 90 days. Please refer to the MedSolutions Precertification List for procedures.  Or you may fax the MedSolutions Universal Request Form to (888) 693-3210. All other requests for information should be directed to the MSI Information Line at (888) 693-3211. 

Aetna Golden Medicare Plan (HMO)-
Effective 5/15/06

Aetna Choice POS
Aetna Select
AEXCEL Plus Aetna Select (HMO)-See Comments
HMO
Open Access HMO
Quality Point-of-Service (QPOS)
USAccess

Identification Card
Choice POS 
HMO 
Open Access HMO
QPOS 
USAccess 

80
Aetna Golden Medicare Plan (HMO)
Effective 5/15/06

224
Aetna Choice POS
HMO
Aetna Open Access HMO
AEXCEL Plus Aetna Select
Quality Point-of-Service (QPOS)
USAccess

338 - Invoice Level Facility Billing

• Varies with benefit plan - see ID Card
• Patient is responsible for copays, deductibles and non-covered services.
• Copay does apply to allergy services, including injections.

• Claims should be submitted on a standard HCFA 1500 form or via electronic transmission (NEIC ID# 60054).
• Claims should be submitted within 95 days from the date of service.
• When filing for secondary benefits, claim should be submitted within 120 days from the date the primary carrier processed the payment decision.
• Aetna Clean Claim Requirements

• Clean paper claims to be paid within 45 days of receipt and no later than 60 days and clean electronic claims to be paid within 30 days of receipt.

• Psychiatric or Substance Abuse services vary by employer groups. You may contact Magellan at (800) 424-5707 to be directed to the proper network.
• For DME, Home Health Care and Home Infusion Therapy services, call (800) 624-0756.
  
• Aetna introduced the Aexcel network - a subset of the current HMO network of specialists. It focuses on six specialities: Cardiology, Cardiothoracic Surgery, Gastroenterology, General Surgery, Ob/Gyn , and Orthopedic Surgery. Members will be subject to one copay/coinsurance level for utilizing an Aexcel provider. All of the UTSW physicians in those 6 specialties are participating in the Aexcel network.