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When you request benefits for an Aetna patient, include any Dx codes you plan to bill. What does that mean for healthcare providers? When employer groups write their own coverage policies, coverage and diagnosis restrictions can differ greatly from one employer to the next. Some employer group plans are more restrictive than Aetna’s corporate standard, while others are more inclusive, allowing a wider range of diagnoses and procedures. Many employer groups are writing their own coverage policies for acupuncture.
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In 2018, we’ve seen a notable increase in the number of employer group plans that allow acupuncture, but do not follow CPB #0135. It provides a list of approved procedure (CPT) and diagnosis codes that can be used when billing acupuncture for an individual plan.įor the last several years, employer group plans have usually followed the guidelines listed in CPB #0135.īut we recently identified an emerging trend that affects many new Aetna patients. For Aetna patients with an individual plan, CPB #0135 is an invaluable resource. As Acubiller’s benefit team researches policy information for our growing client base, we look for emerging trends in coverage.Īetna’s corporate coverage guidelines for acupuncture are laid out in Clinical Policy Bulletin #0135. The information for Timely Filing is found on page 4 under the 8.302.2.11 portion section A.If there’s one thing we can count on in the American insurance industry, it’s change.īilling techniques, filing requirements, and policy details can (and often do) change dramatically from year to year.
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(Note that the claim still must have been received and processed by Conduent within two years of the date of service, regardless of the payment issue with the primary payer.) The Medical Assistance Division (MAD) has advised that claims that exceed the 210 day final filing limit will otherwise not be considered for payment. For each claim submit an original red claim form and attach a reconsideration request with explanation of the circumstance that caused the delay and proof that the claim was submitted to the primary insurance within the above timeframe. If you have claims that were submitted within the 90 day limit from the primary insurance’s payment date but denied for timely filing due to the 210 day final filing limit policy AND you have proof the claims were submitted to the primary insurance within 90 days of the date of service AND either a delay in processing the claim or appeals and reconsideration requests caused the claim to exceed the 210 day final filing limit the claims can be resubmitted with a reconsideration request. It is the provider’s responsibility to submit the claim to another primary payer within a sufficient timeframe to reasonably allow the primary payer to complete the processing of the claim and also meet the MAD timely filing limit. When the provider can document that a claim was filed with another primary payer including Medicare, a HSD contracted MCO (when Medicaid fee for service should have been billed instead), Medicare replacement plans, or another insurer, the claim must be received by Conduent within 90 calendar days of the date the other payer paid or denied the claim as reported on the explanation of benefits or remittance advice of the other payer, not to exceed 210 calendar days from the date of service.