Tag: Aetna
Aetna Changes in NPL
Changes in National Precertification List
As of August 1, 2025, we require precertification for the following:
- Conexxence (denosumab-bnht, J3490, J3590, C9399)
- Bomyntra (denosumab-bnht, J3490, J3590, C9399)
- denosumab-bnht (biosimaliar Prolia, J3490, J3590, C9399)
- denosumab-bnht (biosimaliar Xgeva, J3490, J3590, C9399)
- Omlyclo (omalizumab-igec, J3490, J3590, C9399) (precertification includes the site of care)
- penpulimab-kcqx (J3490, J3590, C9399) (precertification includes the site of care)
- ustekinumab-stba (J3490, J3590, C9399)
- ustekinumab (J3490, J3590, C9399)
- Starjemza (ustekinumab-hmny, J3490, J3590, C9399)
Submitting precertification requests:
Submit precertification requests at least two weeks in advance and include the actual date of service in the request. To save time, request precertification online through our provider portal on Availity.* Doing so is fast, secure and simple.
You can also use your practice’s Electronic Medical Record (EMR) system if it’s set up for electronic precertification requests. Use our “Search by CPT® code” function on our Precertification Lists page to find out if the code requires precertification.***
If you need precertification for a specialty drug for a commercial or Medicare member, submit your request through Novologix®, which is also available on Availity®.
Note to Texas providers: Changes described in this article will be implemented for fully insured plans written in the state of Texas only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.
Health Plan Representatives Updated 8/4/2025
The Health Plan Representatives List has been updated. This is a good tool to print and have close by when you have an issue.
The biggest change for claims issues will be HealthSpring (HCSC) formerly Cigna MA. Here is how:
- Email ALL claims issues to [email protected]
2. HealthSpring has supplied the spreadsheet that MUST be used. A link is provided below, or you may call POET, we will be glad to email you an electronic copy.
Only the columns with Red Lettering, need to be filled out by the Physician’s office.
4. Always feel free to copy [email protected] if you would like POET to be in the loop.
5. If you have a time sensitive, special, or just an issue you would like to discuss with POET, please call (936) 637-7638.
Aetna OfficeLink Updates May 2025
May 2025
This month’s reminders:
We regularly review and adjust our clinical, payment and coding policies. Review our policies and claim edits on our provider portal on Availity®.* Just go to Payer Space > Resources > Expanded Claim Edits. Or you may visit Aetna.com to see them.
Coding/billing update: To align with CMS, starting August 1, 2025 we’ll no longer cover 88305 (Level IV surgical pathology, gross and microscopic examination) when billed with 55700 and/or 55706 (prostate incision procedures) on the same date of service. We’ll also allow G0416 (surgical pathology, gross and microscopic examinations) once per date of service.
Note to Texas providers: Changes described in this article will be implemented for fully insured plans written in the state of Texas only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article
Aetna Fee Schedule Update Effective Today
However, Aetna tells POET the fee schedule is not ready for them to send out, yet.
Aetna Reverses NPP Payment Reduction
By: Hannah Wisterman ~ 2/12/25
On January 31st, InK reported Aetna was changing it’s policy on billing for Non-Physician Providers (NPP). As of February 10th Aetna has changed their stand. Please Read!
Aetna’s Feb. 10 reversal preserves NPPs’ ability to fully bill under a supervising physician’s name and National Provider Identifier (NPI) for services “incidental to” the physician’s diagnosis and treatment of an injury or illness. Services billed incident-to must be conducted in the same office suite where the physician is present and available to intervene if needed.
Aetna Cuts Payment for NPP-Care
By Alisa Pierce ~ TMA
UPDATE: Please see update to this article, posted 2/13/25
Starting April 1, Aetna will pay physician practices only 85% of the Medicare Physician Fee Schedule’s allowed amounts for services provided by non-physician practitioners (NPPs)
This will be regardless of whether you bill Medicare directly or “incident-to” physician supervision.
- Both direct and incident-to claims will still be required to include modifiers SA or SB to indicate what type of NPP rendered the service, such as a nurse practitioner or certified nurse midwife.
- NPPs will still be required to be employed by supervising physicians and registered with the Texas Medical Board as having delegated prescriptive authority.
“This is essentially [Aetna] getting rid of incident-to billing,”
Aetna OfficeLink Updates 12/1/2024
Claim and Code Review Program (CCRP) Update
Aetna states in their newsletter
“We might have new claim edits for our commercial members.
Beginning March 1, 2025, you may see new claim edits. These are part of our CCRP. These edits support our continuing effort to process claims accurately for our commercial members. You can view these edits on our provider portal on Availity.*
For coding changes, go to Aetna Payer Space > Resources > Expanded Claim Edits
You’ll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to our provider portal on Availity. You’ll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools.
We may request medical records for certain claims, such as high-dollar claims, implant claims, anesthesia claims, and bundled services claims, to help confirm coding accuracy.”
G-Code Frustration
Deepening ongoing physician concerns over the implementation of Medicare’s add-on code for complex care, two major payers have either reduced payment for G2211 claims or announced plans to stop paying certain claims associated with the code altogether for particular plan members.
Aetna March OfficeLink Updates
Changes in Aetna’s Commercial Drug List Begin on July 1, 2024.
Per Aetna, Changes may affect all drug lists, precertification, step therapy and quantity limit programs. Physician offices can view the changes as early as May 1, 2024. The changes can be found on Aetna’s Formularies and Pharmacy Clinical Policy Bulletins page.
Changes in Aetna’s National Precertification List (NPL)
This applies to both Aetna Commercial and Medicare Members. (POET does not have an Aetna Medicare contract at this time.) Per Aetna this change will also be effective July 1, 2024. They will require precertification for:
- Osteotomy posterolateral approach, thoracic
- Osteotomy anterior approach
- Knee meniscectomy-requires precertification for the Medicare Advantage members only.
Per Aetna, Be sure to submit precertification requests at least two weeks in advance. To save time, request precertification on line.
Updated Clinical Prior Authorization
Assistance Chart Now Available
An update to the Clinical Prior Authorization Assistance Chart is available. The chart identifies which clinical prior authorization each MCO uses and whether the MCO uses all or some of the steps in the evaluation process.
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