1. OctOber 20060
SPrING 201
VOlume 5, ISSue 1
Aetna Behavioral
Aetna Behavioral
Health Insights ™
Health Insights
TM
Behavioral Health Newsletter
Inside this Issue Precertification requirements for psychological and
■ Autism and Applied Behavioral Analysis 2 neuropsychological testing
■ Visit our behavioral health web page 2
■ Aetna Behavioral Health Insights – all Keep the following in mind when differentiation of brain damage
electronic 3 requesting precertification and/or from a depressive disorder, epilepsy,
■ Don’t forget OfficeLink 3
■ Aetna BH Insights available online
submitting claims for psychological and hydrocephalus, Alzheimer’s disease,
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neuropsychological testing: Parkinson’s disease, multiple sclerosis
OFFICE TOOLS or AIDS). Please check to be sure
■ Precertification (where permitted
■ Tool helps determine patients’ costs 4 the member does not have a medical
or approved) is required when
■ Facilities moving locations 4 precertification requirement which may
■ Updated EAP Billing Form online 4
neuropsychological or psychological
necessitate a referral.
■ HIPAA communications 5 testing is a covered benefit and is
■ Electronic provider contracting 5 requested for the evaluation of a mental ■ Pre-surgical clearance: An evaluation
■ Update your profile 5 health diagnosis (for example, serious by a psychologist or psychiatrist
psychiatric illness). (CPT 90801) is sometimes required
FOCUS ON QUALITY
for pre-operative clearance (such as
■ Quality Management Program 6 ■ Precertification is not required when
for obesity surgery). A psychological
■ How we determine coverage decisions 7 neuropsychological or psychological
■ 2009 QM Program evaluation 8 or psychiatric evaluation (as opposed
testing is a covered benefit and is
■ Where to find Member Rights and to psychological testing) is a routine
Responsibilities 8 requested for the evaluation of a
outpatient procedure and does not
■ BH Clinical Practice Guidelines 9 medical diagnosis (for example,
require precertification.
■ Practitioner Treatment Record Criteria 9 traumatic brain injury, stroke,
CONTACT US 10
Applied behavior Analysis to require precertification
Beginning April 1, 2010, Applied To access the Aetna Behavioral Health
Behavior Analysis (ABA) requires and Employee Assistance Program page:
precertification (where permitted ■ Log in to our secure provider website.
or approved). (ABA is used in the
treatment of Autism Spectrum ■ Choose “Aetna Support Center.”
Disorders.) ■ Select “Doing Business with Aetna”
Go online to our secure provider followed by “Aetna Benefit Products.”
website via NaviNet® to view a copy of
our current Aetna Behavioral Health
precertification list, which includes full
details and exclusions.
48.22.804.1 (3/10)
2. HIPAA and communication between treating providers
Concerns about Health Insurance by fax 2. You may leave a message with a family
Portability and Accountability Act 1. Before faxing any PHI, call to confirm member or other person who answers
(HIPAA) Privacy Rule violations are the appropriate fax number. the phone when the patient is not
occasionally raised as a reason why home, though professional judgment
2. Always use a cover sheet marked
providers are hesitant to share patient should be used to ensure that such
CONFIDENTIAL with your name
treatment information with other health disclosures are limited and in the best
and telephone number as the contact
care professionals. HIPAA was created interest of the patient.
information.
to protect people’s protected health
3. Reasonable requests from a patient to
information (PHI), not to act as a barrier 3. Confirm fax has been received by the
communicate in a confidential manner,
to the communication between treating intended recipient.
such as at a different number, should
providers.
by email be accommodated.
To help maintain HIPAA compliance, 1. Confirm that your computer can send
For more information, refer to the U.S.
here are some tips when sending an encrypted document.
Department of Health and Human
confidential PHI:
2. All PHI must be sent in an encrypted Services website at: http://www.hhs.
by mail format. Never include identifying gov/ocr/privacy/hipaa/understanding/
1. When mailing paper PHI, place the information in the subject line. coveredentities/index.html
records in an inner envelope and seal
3. Confirm the recipient’s email address We ask that you share this information
the envelope. Mark the inner envelope
prior to sending PHI. with your staff.
CONFIDENTIAL.
4. Verify receipt of encrypted email.
2. Place a shipping label on the inner
envelope. by telephone
1.You may leave messages on a patient’s
3. Place the first envelope within a second
answering machine, though care
envelope or box.
should be taken to limit the amount of update your profile,
4. Place a DUPLICATE shipping label on information disclosed.
including languages
the external envelope or box.
spoken
5. Confirm package has been received.
We want to be sure our members
have access to your most up-to-
date information in our provider
Provider contracting is easier with new electronic system directory, including details such as
specialty focuses, office locations and
Aetna is the first insurance care company to introduce electronic provider contracting. languages spoken.
Providers will now be able to receive and sign provider agreements via email, making
the contracting process faster and more reliable. With this system, providers will enjoy Update your profile online at:
ease of administration, reduced paper clutter and cost savings on postage. https://www.aetna.com/provider/
We are working with EchoSign as our eSignature vendor. EchoSign’s software bh_profile_update.html
conforms to compliance, legal and security requirements. To learn more about
EchoSign and their eSignature solution, visit www.EchoSign.com.
So be sure to check your inbox – an electronic provider contract for new associates in
your practice may be arriving soon.
If we do not have your office email address, you can submit it to us:
Physicians: https://aetna.providerpreference.com/
Facilities: https://aetna.providerpreference.com/facilities.php
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3. From the desk of Mark Friedlander, M.D., National Associate Medical Director,
Aetna Behavioral Health
Autism and Applied behavior Analysis
Autism is considered to be a spectrum services in their plan documents (most While Aetna does not support a mandate
of disorders with variable presentations do), thereby eliminating coverage for for autism coverage, we do support review
and severities, leading to the preferred Applied Behavior Analysis (ABA), which of proposed benefits mandates by an
use of the term Autism Spectrum Aetna considers to be educational (as independent body to assess their medical
Disorders (ASD). supported in the position papers of the and financial impact. This is especially
American Academy of Pediatrics and true given that the efficacy of ABA may
Among other factors, the increasing the National Academy of the Sciences). be limited to only a subset of children
awareness of ASD has resulted in earlier Self-funded plan sponsors may choose with ASD.
and more frequent recognition of the to retain the exclusion for educational
condition, so that when broad diagnostic services for fear that coverage of ABA will Adding autism coverage would have a
criteria are used, the incidence of newly result in an unlimited benefit due to the significant financial impact on many
identified children with ASD may be Federal Mental Health Parity Act. policyholders. Therefore, if a state is
as high as 6 per 1,000. Despite much considering the passage of mandated
research into the causes, treatments and This Act requires group health plans autism coverage, we would like to see
outcomes, there is no single and correct (self-funded or fully-insured) and health the following features included in
approach that universally works best in insurance issuers to ensure that financial the mandate:
all circumstances. requirements (such as copays and
deductibles) and treatment limitations
■ Treatment must be provided by licensed
being part of the solution (such as visit limits) applicable to or BACB-certified ABA providers
There is clearly a need for commercial mental health or substance use disorder located in the insured’s state
health insurance to be part of the benefits are no more restrictive than the ■ Application of the mandate to large
solution. Aetna Behavioral Health’s predominant requirements or limitations group and public plans only
resources, including specialized networks, applied to substantially all medical/
data analytics, integrated medical and surgical benefits. Therefore, if a plan
■ Standard utilization review according to
behavioral health systems, resource and contains coverage for ABA, such benefits policy terms
utilization management capabilities, cannot be any more limited than the ■ Coverage required for evidence-based
enable us to play an active role in medical/surgical benefits. Most Aetna treatment only
coordinating and helping to manage the benefits plans have few, if any, limits on
health care needs of this population. the medical/surgical side, resulting in ■ Enhancement and not replacement of
unlimited ABA (absent the educational existing educational services
Since most state autism mandates do not
apply to self-funded plans, it is up to the exclusion).For fully-insured plans, we
plan sponsor to decide whether they will exclude ABA if there is an educational
elect to cover autism. The self-insured exclusion in the plan documents and if
plan sponsor also decides whether to the plan is not subject to a state mandate.
retain the exclusions for educational Our stance on mandated coverage
Several state mandates require health
insurance carriers to recognize and
reimburse certified or licensed providers.
Fast facts on ASD/AbA Our benefits plans typically require Aetna bH Insights
that services be provided by licensed
Not every child will respond to early available online
■
clinicians. In the ASD field, there are
intensive behavioral interventions,
regardless of how much is provided.
practitioners with credentials indicating Access this month’s
competency (ABA certification) who
■ If the benefits plan covers ABA and would not qualify for independent newsletter, as well as past
the plan is subject to the Federal licensure in the jurisdiction in which issues, by logging in to our
Mental Health Parity Act, the plan
cannot subject ABA to limits that they work. These individuals can now secure provider website.
are more restrictive than the limits become in-network providers with Search for back issues under
that exist for medical benefits. Aetna Behavioral Health, as well as
(Note: Most Aetna benefits plans with other carriers.
“Communications.”
have few, if any, limits on medical
benefits, resulting in unlimited ABA
2 coverage.)
4. reminder: Aetna Behavioral Health Insights now all-electronic
Beginning with our last issue, the Aetna Behavioral Health If your email address has changed recently, make sure you
Insights newsletter is only available to you through email. update it at the following addresses:
We no longer produce paper copies.
Physicians and behavioral health care providers:
We want you to stay connected and keep receiving the critical https://aetna.providerpreference.com
information this newsletter offers. To help ensure you continue
Hospitals and facilities:
to get the newsletter, we need to have your most current
https://aetna.providerpreference.com/facilities.php
email address.
Visit our behavioral health page for tools, resources
We maintain a comprehensive Aetna Behavioral Health and Employee Assistance
Program page on our secure provider website designed to make working with us
easier. This dedicated page offers information, tools and resources for behavioral
health professionals.
Visit us often – we’re always posting new information and tools.
to access the Aetna behavioral Health and
employee Assistance Program page:
■ Log in to our secure provider website.
■ Choose “Aetna Support Center” from upper left menu.
■ Select “Doing Business with Aetna” followed by “Aetna Benefit Products.”
Don’t forget about OfficeLink
As a reminder, Aetna OfficeLink Updates™ — our quarterly newsletter for medical providers and other health care
professionals— may also contain information useful to behavioral health practitioners. You can access issues of this publication
at: http://www.aetna.com/healthcare-professionals/news/regional_hcp_newsletters.html.
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5. Office Tools
New tool helps you determine patients’ FAcIlItIeS
out-of-pocket costs
moving locations?
High-deductible health plans can make ■ Provide printable information to help let us know in advance
it more difficult to calculate how much a you initiate financial discussions with
It is important that inpatient, intensive
patient will owe. How would you like a patients prior to, or at time of, care
outpatient, partial hospitalization or
convenient online tool that will estimate ■ Reduce and potentially eliminate any other group organizations contact
out-of-pocket costs for your Aetna
after-the-fact financial surprises for you us prior to moving.
patients before services are rendered?
and your patients
Notifying us in advance will help
Allow us to introduce Aetna’s new
Phased roll-out for provider tool ensure that your claims are paid in a
Payment Estimator for providers,
Check to see if your office has access: timely manner. It will also allow us to
available soon through our secure
begin any necessary recredentialing
provider website. The Payment Estimator ■ Log in to NaviNet, and look for at your new location so that there
supplies an estimate of what we will Payment Estimator in your Aetna is no disruption to your network
pay a participating provider, as well as transaction menu. participation status.
an estimate of the amount the patient
■ Visit the Aetna Payment Estimator
will owe.
website and select Workflow Integration
How the Payment estimator works to learn more. Be sure to check out
Before or on the day of a patient’s visit the Information for your Patients
or procedure, your office enters basic section for tips on providing estimate
updated eAP billing Form
member information, diagnosis and information to your patients.
procedure codes, and clicks “submit!”
available online
take our online course
The Payment Estimator will: We recently updated the EAP
Visit www.AetnaEducation.com to
Provider Billing Form. To access a
■ Confirm eligibility and verify enroll in our Payment Estimator for
copy, go to the Aetna Behavioral
behavioral health benefits providers online tutorial, available
Health and Employee Assistance
in April.
■ Supply your office with an estimated Program page or the Forms Library
Aetna payment amount on our secure provider website.
■ Give reliable estimates of patient
copayments, coinsurance,
deductibles, etc.
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6. Focus On Quality
About our Quality management Program
We are committed to a continuous ■ Adhere to all Aetna policies and ■ Support on-site audits or requests for
quality improvement program and procedures, including those outlined treatment records
encourage health care professional in the Aetna Behavioral Health Provider ■ Complete and return annual provider
involvement through committee Manual
satisfaction surveys when requested
participation. The Aetna Quality ■ Communicate with the member’s
Management Program includes: ■ Participate in treatment plan reviews or
primary care physician as warranted
send in necessary requests for treatment
■ Quality improvement activities (after obtaining a signed release)
in a timely fashion
■ Prevention programs ■ Comply with treatment record ■ Submit claims with all requested
standards, as outlined in our provider
■ Utilization management program information completed
manual
■ Disease management programs ■ Adhere to patient safety principles
■ Respond to inquiries by our behavioral
■ Outcome studies health staff in a timely manner ■ Comply with state and federal laws,
including confidentiality standards
■ Treatment record review programs ■ Cooperate with our complaint process
■ Cooperate with quality improvement
■ Oversight of availability and access ■ Follow continuity-of-care and
activities
to care transition-of-care standards when the
member’s benefits are exhausted or if If you have questions about our Quality
■ Member safety
you leave the network Management Program, or would like to
■ Complaints, non-authorizations and receive a copy of the program description
appeal processes or Annual Quality Management
Evaluation results, contact
Participating behavioral health care
Jennifer Eissfeldt at 215-766-7045 or
professionals are required to support our
EissfeldtJ@aetna.com.
Behavioral Health Quality Management
Program, be familiar with our guidelines
and standards, and apply them in their
clinical work. Specifically, behavioral
health care professionals are expected to:
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8. 2009 Quality management Program evaluation
Aetna Behavioral Health annually ■ Continuity and coordination of ■ Streamlined UM program
evaluates our Quality Management behavioral health care ■ HEDIS® measures
Program and addresses key area findings, ■ Continuity and coordination of medical
such as: For additional information on our 2010
and behavioral health care
Quality Management Program or the
■ QM committee structure ■ Provider treatment record review results of our 2009 evaluation, log in to
■ Annual policy review our secure provider website and select
■ Case manager and customer service
Aetna Support Center, Doing Business
■ Patient safety representative quality review audits
with Aetna, Aetna Benefit Products, then
■ Availability and accessibility ■ Utilization management criteria and Aetna Behavioral Health and Employee
decision turnaround time Assistance Program. If you do not have
■ Complaints and appeals (incorporated
Internet access, contact Jennifer Eissfeldt
into “Member Services” section) ■ Prevention programs
at 215-766-7045 or EissfeldtJ@aetna.com.
■ Member satisfaction and provider ■ Clinical specialty programs HEDIS refers to the Healthcare Effectiveness
satisfaction Data and Information Set; HEDIS is a
■ Quality improvement initiatives registered trademark of the National
Committee for Quality Assurance.
■ Clinical Practice and Preventive Health ■ Delegation
Guidelines
■ Medicare over/under utilization
monitoring
member rights and
responsibilities available
online
Our Member Rights and
Responsibilities are available online in
the Aetna Behavioral Health Provider
Manual posted on our secure provider
website:
■ On the home page, select “Doing
Business with Aetna.”
■ Choose “Aetna Benefit Products.”
■ Scroll down to “Behavioral Health
and Employee Assistance Program.”
If you would like a copy of Aetna’s
Member Rights and Responsibilities
Statement, call 1-888-632-3862.
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9. Practitioner treatment record criteria
Aetna requires participating behavioral Further, Aetna will have access to Delegated providers
health practitioners to maintain treatment records, including confidential Additionally, Aetna conducts treatment
administrative, technical and physical member information, for the purpose of record reviews for delegated providers.
safeguards to protect the privacy of claims payment; assessing quality of care,
treatment record Standards
members’ protected health information including medical evaluations and audits;
For a description of our Practitioner
(PHI). and performing utilization management
Treatment Record standards, refer to
functions.
Participating practitioners must treat the our Behavioral Health Manual on the
following as confidential – information Performance assessment goals Aetna Behavioral Health and Employee
that: To assess the quality of treatment record- Assistance Program page of our secure
keeping practices, we will maintain a provider website. We also post Treatment
■ Identifies a member
performance goal, assess for opportunities Record Review Best Practices on our
■ Specifies the relationship of the member to improve treatment record keeping secure provider website under “Focus on
with Aetna and implement actions to improve Quality” on the Behavioral Health page
medical record-keeping practices. Each
■ Addresses physical or mental health
record must be measured against these
status or condition, provisions of health
performance ranges:
care, and payment for the provision
of health care to the member as ■ 90–100 Performance goal
confidential in accordance with their
■ 80–89 Minimal deficiencies
Aetna contract and applicable laws
■ 70–79 Moderate deficiencies –
maintaining records
corrective action plan
Participating practitioners also must
maintain treatment records in a current, ■ 69–below Serious deficiencies –
detailed, organized and comprehensive corrective action plan,
manner in accordance with customary re-audit within six
clinical practice, applicable laws and months
accreditation standards. This requirement
survives the termination of the contract,
regardless of the cause for termination.
consult behavioral Health clinical Practice Guidelines
The following Behavioral Health Clinical Practice Guidelines (CPGs) are based on nationally recognized recommendations and
peer-reviewed medical literature. They are posted on our secure provider website under “Clinical Resources” and on the Aetna
Behavioral Health and Employee Assistance Program page. Updated CPGs will be posted in April.
■ Helping Patients Who Drink Too Much Updated 3/10
■ Treating Patients With Major Depressive Disorder Updated 3/10
To get a hard copy of a specific CPG, call our Provider Service Center.
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