Aetna cpt code reimbursement

Our goal is to keep you as well informed about our plan as possible. Be sure to check this page often. We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes. In an effort to keep our providers informed, please see the below chart of upcoming new policies.

An Excludes 1 Note indicates that the excluded code identified in the note should never be used at the same time as the code or code ranges above the Excludes 1 Note in the ICD10 manual. An Excludes 1 Note is used to indicate when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. These conditions are mutually exclusive code combinations.

Thank you for your continued commitment to improving the health of our members — your patients. With a few exceptions listed below, these codes will no longer be managed through the prior authorization process. They will be managed with Medical Records at the time of claim submission. That is, records supporting the use of these codes must be submitted with the claim.

If records are not submitted with any claim including one of the codes listed below, the claim will be denied for lack of documentation. You may resubmit the claim with required supporting records. ACIP regularly reviews all formulations of vaccines and updates its list of recommended vaccines. In previous years, the list included a live attenuated Influenza vaccine LAIV for individuals aged in a nasal spray formulation Flumist. ACIP continues to recommend annual flu vaccination with either the inactivated influenza vaccine IIV or recombinant influenza vaccine RIV for everyone 6 months and older.

These vaccines are available through a participating pharmacy.

Aetna Telehealth Billing for Therapy and Mental Health Providers

Skip to main content Main Navigation. Provider notices Subject: New Policy Updates - Clinical Payment, Coding and Policy Changes Date: July 1, We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes.

Subject : Fluoride varnish Date : Oct. Only trained providers will be reimbursed. Online training can be completed at www. One provider per facility needs to complete the online curriculum and can then train their colleagues. Providers who have completed the training must sign a form attesting they have completed the curriculum. The form is on our website. Fluoride varnish supplies can be obtained by contacting Henry Schein at or Benco at The guidelines vary depending on the payer and your state, and are even shifting as we speak as new telemedicine policy gets passed.

This month, we move on to another category of payer — the private, commercial payers. Do they cover it? What guidelines do they have for billing? Here are the top 10 FAQs about telemedicine reimbursement and private payers. Telemedicine parity laws are state laws that require private payers to reimburse telemedicine services the same way they would for in-person medical services.

That means, if your state has a telemedicine parity law in place, then your private payers have to reimburse you! Right now, 29 states plus DC have passed telemedicine parity laws. An additional 8 states have proposed telemedicine parity laws on the table. To track telemedicine parity in your state, bookmark this fantastic state policy matrix from the ATA.

They update it on a regular basis. If your state has a telemedicine parity law, any of the private payers in your state should cover telemedicine.

aetna cpt code reimbursement

This means a patient with a BCBS gold plan in North Carolina could have telemedicine listed on their policy as a covered health service; a patient in the same state with a BCBS silver plan might not. So just knowing whether the private payer covers telemedicine is not always the whole answer.

We recommend verifying their insurance before doing the first telemedicine visit. The easiest way to check telemedicine coverage is always just to call the payer and ask the right questions. Make sure when you call that you record everything with an insurance verification form. You can use our sample form here. Having that paper filled out and on file is your golden ticket to getting paid.

While some payers do cover store-and-forward and remote patient monitoring services, the gold standard is live video telemedicine. Many also reimburse for a variety of mental health and chronic care services. Some do follow the more restrictive Medicare model where a patient needs to come into a local health facility and do the telemedicine visit from there. But many private payers are catching onto the new idea of telemedicine as care delivered to the patient at their convenience from home, work, or anywhere and are lessening these restrictions.

Private payers vary on this one. Always verify the accepted billing codes for telemedicine before you do the visit. Many of the large private payers have recently begun or are finishing up large telemedicine pilot programs to analyze the benefits of telemedicine. As the results start to come in and show significant cost-savings and positive effects on care quality and patient outcomes, private payers will be highly motivated to expand their reimbursement policies for telemedicine.

That was a lot of information to consume. While answers to reimbursement questions are rarely black-and-white, this summary should give you some helpful context of how to approach telemedicine reimbursement with private payers.

Teresa Iafolla is an expert writer, researcher, and content wrangler who has previously worked as director of content marketing for a telehealth company and associate editor for a healthcare publishing company. Sign up for weekly, thought-provoking content on telemedicine news, straight to your inbox.

Sign up for weekly, thought-provoking content on telemedicine news, straight to your inbox.

About Teresa Iafolla Teresa Iafolla is an expert writer, researcher, and content wrangler who has previously worked as director of content marketing for a telehealth company and associate editor for a healthcare publishing company.

Read More. The eVisit Blog.Third-party reimbursement is affected by many factors. This document and the information and assistance provided by Janssen CarePath are presented for informational purposes only.

They do not constitute reimbursement or legal advice. Janssen CarePath does not promise or guarantee coverage, levels of reimbursement, or payment. The fact that a drug, device, procedure, or service is assigned an HCPCS code and a payment rate does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the Medicare program.

Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. Accordingly, the information may not be correct or comprehensive. Janssen and its third-party service providers strongly recommend you consult your payer for its most current coverage, reimbursement, and coding policies.

Janssen and its third-party service providers make no representations or warranties, expressed or implied, as to the accuracy of the information provided. In no event shall the third-party service providers or Janssen, or their employees or agents, be liable for any damages resulting from or relating to any information provided by, or accessed to or through, Janssen CarePath. All HCPs and other users of this information agree that they accept responsibility for the use of this program.

Commercial payers may use these codes or alternate codes and Chemotherapy administration, intravenous infusion technique, up to one hour, single or initial substance. Chemotherapy administration, intravenous infusion technique, each additional hour, single or initial substance list separately in addition to code for initial hour of infusion services.

Non-Medicare payer policies regarding the use of and may vary. Alternatively, some may prefer use of CPT codes IV infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour and IV infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; each additional hour.

List separately in addition to code for primary procedure. Please consult your local payer for specific coding policies or call Janssen CarePath for assistance at CarePath Coverage varies by carrier and individual patient case.

Keep the following tips in mind to help ensure that your documentation is thorough and accurate:.Telemedicine is trending in the United States and it is widely believed that some day soon all insurance coverage will include video visits and that providers will be reimbursed in the same way they are for in-office visits.

aetna cpt code reimbursement

However, that is not yet the case. Coverage for telehealth still varies from state to state and payer to payer. Aetna and other payers are subject to these requirements for most plans.

Reimbursement Consulting Services

There are some exceptions, however. Some state laws mandate that providers receive the same amount of payment for a video visit as for an in-office one of the same type. Other states leave the exact reimbursement amounts up to the insurer. Each state law also spells out the types of telemedicine that are covered. Every state that has such a law includes video visits. Several also cover store-and-forward telemedicine, but this is less common, and most do not include audio only calls.

Unlike Blue Cross Blue Shield and several other large payers that have fully embraced telemedicine, Aetna takes a more conservative approach. They have partnered with TeleDoc to provide telephone consultations for non-urgent conditions for patients with certain plans.

If your state does not have a reimbursement requirement, such a claim might be denied. Because telehealth coverage for Aetna patients is such a mixed bag, and because plans and policies change all the time, it is smart for practices to choose telemedicine software with built-in eligibility verification.

Our experts keep track of regulations and payer policies, constantly updating the system with the latest information. Video visits are convenient for patients and a great way to grow your practice. Coverage under Aetna varies, so it is a smart idea to select a telemedicine software provider that can accurately and easily verify coverage for patients covered by Aetna. Toggle navigation. Aetna Telemedicine Reimbursement. Your Guide to Reimbursement for Patients Covered by Aetna Telemedicine is trending in the United States and it is widely believed that some day soon all insurance coverage will include video visits and that providers will be reimbursed in the same way they are for in-office visits.

Eligibility Verification for Aetna Patients Because telehealth coverage for Aetna patients is such a mixed bag, and because plans and policies change all the time, it is smart for practices to choose telemedicine software with built-in eligibility verification.

Claims, Payment & Reimbursement

Offer patients convenience Video visits are convenient for patients and a great way to grow your practice. Ready to offer telehealth to your patients?If your browser is in Private mode, pages that use personal or geographic information may not work. Learn more about private mode.

Our provider cost estimator tool helps your office estimate how much your patients will owe for an office visit or procedure. And it approximates how much Aetna will pay for services. Patient cost estimator is available on our provider portal on Availity. Log in to our provider portal. This tool provides fee information for a sample scope of services that a doctor can provide. Contracted physicians can access fee schedules online on our secure provider website. Note that physician fee schedule information will not display accurate rates for care services provided to Aetna members who participate in an accountable care organization ACO arrangement.

Providers should use the provider payment estimator tool to estimate costs for these patients. Access our physician fee schedules. Use our secure provider website to access electronic transactions and valuable resources to support your organization. In order to have the best experience on Aetna. Learn how to change your browser settings to enable Javascript. Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. Do you have Aetna insurance through an employer or are you a Medicare member?

Yes No. Skip to main content. Join our network. How to apply How to apply. Request participation. Medical professionals or part of a medical group.Under the policy, we'll reimburse for two-way, real-time audiovisual interactive communication between the patient and the health care practitioner.

aetna cpt code reimbursement

This interaction does not include direct patient contact, but the patient must be present and take part throughout the interaction.

This updated policy will take effect as of January 1, At that time, you will be able to review the payment policy and approved codes on the provider website. When billing for eligible services rendered via telemedicine, as explained above, you must bill them using the appropriate telemedicine modifier representing two-way, real-time audiovisual interactive communication.

Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. The information you will be accessing is provided by another organization or vendor. If you do not intend to leave our site, close this message. Contact us Espanol. Join our network. How to apply. Patient care program overview Health care report cards Aetna specialty institutes Aexcel performance networks Physician advisory board.

Getting started as a new provider. Health care providers. Pharmacy services. Drug lists. Pharmacy clinical policy bulletins. Update pharmacy data. CPT code search. Clinical policy bulletins.This policy covers the cost of a physician-ordered test and the office, clinic or emergency room visit that results in the administration of or order for a COVID test. The test can be done by any approved laboratory.

This member cost-sharing waiver applies to all Commercial, Medicare and Medicaid lines of business. The policy aligns with new Families First legislation requiring all health plans to provide coverage of COVID testing without cost share.

The requirement also applies to self-insured plans. Commercial labs are in the process of updating their provider community about their capabilities and how to order tests. Instead, an appropriate specimen should be collected at the health care facility where the patient was seen and the test was ordered. The specimen should be sent to these laboratories using standard procedures.

Quest Diagnostics. Accurate Diagnostics Labs. Sonic Healthcare CBL. To check whether other commercial labs, hospitals or urgent care centers are authorized to provide COVID lab testing, visit their respective websites. By submitting a claim to Aetna for COVID testing, providers acknowledge that the above amounts will be accepted as payment in full for each COVID test performed, and that they will not seek additional reimbursement from members. Quest and LabCorp will not collect specimens for the test.

Patients for whom testing has been ordered should not be sent to a Quest or LabCorp location or their draw sites to have a specimen collected. Test results will be available in three to four days. The physician office will put in a sealed envelope and ship it out to the lab. The labs will communicate and educate the providers offices on using the appropriate lab testing equipment and submitting to their reference lab.

Commercial labs have been preparing for additional testing capabilities. Aetna is in contact with commercial labs and tracking the availability of new lab tests. This policy applies to all Aetna-insured commercial plan sponsors and is effective immediately for any such admission through June 1, Self-insured plan sponsors will be able to opt-out of this program at their discretion.

We will also cover the cost of the hospital stay for all of our Medicare Advantage members admitted March 25, through June 1, Regulations regarding cost-sharing for Medicaid beneficiaries vary by state and continue to evolve in light of the current situation. We have suspended cost-sharing requirements, including premiums and copays, for adults and children covered by Medicaid and CHIP, in those states where permitted to do so by the appropriate regulators.

This change is effective immediately and will apply to any such admission between March 25, and June 1, All claims received for Aetna-insured members going forward will be processed based on this new policy. If in-patient treatment was required for a member with a positive COVID diagnosis prior to this announcement it will be processed in accordance with this new policy.

In the event a claim has already been processed prior to this policy going into effect, members should contact Customer Service so the claim can be reprocessed accordingly.


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