| Applies To |
All MCO Credentialed Faculty**
EXCEPT*(See Notes at the Bottom of Page):
- All Psychiatry except Neuro Psych is carved out
**For further clarification of "All MCO Credentialed Faculty" refer to the Table of Contents.
|
| PCP Services |
For plans that have a PCP option, members may choose UT Family Practice and General Internal Medicine physicians as their PCP . |
| Laboratory Services |
Includes services performed at:
- Aston Lab-
Does not apply to Aetna Golden Choice Plan -Medicare
- LabCorp
- Quest Diagnostic. Venipuncture fees will be reimbursed for lab drawn and sent to Quest Diagnostic.
|
| Radiology Services |
Includes services performed at:
- Algur H. Meadows Diagnostic Imaging Center
- Aston Radiology
- Mary Nell & Ralph B. Rogers MRI Center
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.
|
| Participating Facilities |
- 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)
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| Referral Requirements |
- 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.
- 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.)
- 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.
- 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:
- Pelvic Ultrasounds and Breast Ultrasounds
- Mammograms-Gynecologic Oncologists
- DEXA scans-Urologists
- Surgeons for Breast /problems
- Our providers are participating in the Aexcel networks for the six specialty categories that represent a high percentage of specialty costs: cardiology, cardiothoracic surgery, gastroenterology, general surgery, obstetrics and gynecology, and orthopedic surgery. Access to Aexcel specialists will be considered direct access to participating specialists enrolled in Aexcel products and your office will not need a referral to treat Aexcel members, even in those products which would otherwise require PCP referral.
For information on Aetna Transplant members
please refer to Aetna National Medical
Excellence Transplant Network
|
| Authorization Requirements |
Effective 09/01/03, for TRS Care Retirees, please refer to the TRS Care Precertification List or call (800) 367-3636. For all other members, please see below.
You can refer to the Aetna Precertification List for all products.
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| Managed Care Plan |
Aetna Golden Choice Plan (PPO) -
Medicare Effective 5/15/06
Aetna Choice POS II
Elect Choice (EPO)
Managed Choice (POS)
Open Access Elect Choice (EPO)
Open Access Managed Choice (HMO)
Open Access Select (PPO)
Open Choice PPO
Traditional Choice (National Advantage Program only)
TRS Coordinated Care (Retirees) - Effective 09/01/03
|
|
Identification Card
ElectChoice
Managed Choice (MC)
Open Access Elect Choice
Open Access MC
Open Choice PPO
Traditional Choice(NAP)
|
"AETNA" - See ID Card |
| FSC |
80
Aetna Golden Choice Plan (PPO)
Medicare Effective 5/15/06
225
PPO
Effective 09/01/03
333
TRS Coordinated Care (Retirees)
339
Invoice Level Facility Billing
|
| Contract Date(s) |
April 15, 1996-Pediatric Services
November 1, 1997-Adult Services
January 15, 2003 - Pediatric and Adult contracts combined.
May 15, 2006- Contracted with Aetna Medicare products.
|
| Eligibility |
Varies with Payors-See ID Card
Note: For TRS Coordinated Care (Retirees) members call (800) 367-3636 |
| Claims Mailing Address |
Aetna
P.O. Box 981106
El Paso, TX 79998-1106
(888) 238-6277
Note: Member's ID card may reflect a different claims mailing address than the one noted above. This claims mailing address is the centralized claims address and should be used for all PPO based plans. |
| Deductible/Co-Payment |
Varies with Payor - See ID Card |
| Claims Submission |
- 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
|
| Claims Payment |
Clean paper claims to be paid within 45 days from receipt by
payorand clean electronic claims to be paid within 30 days
from receipt. |
| Appeals |
Appeal request must be submitted to payor within 180 days of the processing date on the EOB or the date of the denial letter. |
| Provider Relations |
Provider Relations 1-800-624-0756
www.aetna.com |
| Comments |
- Psychiatric services vary by plan.
- Effective 1/1/04 Aetna introduced the Aexcel network - a subset of the current PPO 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, a higher copay/coinsurance for utilizing a provider in the standard PPO network, and a still higher copay/coinsurance for utilizing an out of network provider. All of the UTSW physicians in those 6 specialties are participating in the Aexcel network.
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