Claim and Code Review Program (CCRP) Update
We might have new claim edits for our commercial, Medicare and Student Health members. You can view them on Availity®.

This update applies to our commercial, Medicare, and Student Health members.

Beginning September 1, 2023, 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, Medicare and Student Health members. You can view these edits on our Availity provider portal.*

For coding changes, go to Aetna Payer Space > Resources > Expanded Claim Edits. 

With the exception of Student Health, 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 the Availity provider portal. 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. 

Changes to Commercial Drug Lists Begin on October 1
Find out about drug list changes and how to request drug prior authorizations.

On October 1, 2023, we’ll update our pharmacy drug lists. Changes may affect all drug lists, precertification, step therapy and quantity limit programs. 

You’ll be able to view the changes as early as August 1. They’ll be on our Formularies and
Pharmacy Clinical Policy Bulletins page.

Ways to request a drug prior authorization

• Submit your completed request form through our Availity provider portal.*
• For requests for non-specialty drugs, call 1-800-294-5979 (TTY: 711). Or fax your authorization request form (PDF) to 1-888-836-0730. 
• For requests for drugs on the Aetna Specialty Drug List, call 1-866-814-5506 (TTY: 711) or go to our Forms for Health Care Professionals page and scroll down to the Specialty Pharmacy Precertification (Commercial) drop-down menu. If the specific form you need is not there, scroll to the end of the list and use the generic Specialty Medication Precertification request form. Once you fill out the relevant form, fax it to 1-866-249-6155. 

Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change.

For more information, refer to the Contact Aetna page. Open the “By phone” tab to find the pharmacy management phone number.

Important Pharmacy Updates
For Medicare, Medicare Part B step therapy, and commercial

Medicare
Visit our Medicare drug list to view the most current Medicare plan formularies (drug lists). We update these formulary documents regularly during the benefits year as we add/update additional coverage each month. 

Visit our Medicare Part B step therapy page to view the most current Preferred Drug Lists for Medicare Advantage (MA) and Medicare Advantage with prescription drug coverage (MAPD) members. These lists are updated regularly throughout the plan year. 

Commercial — notice of changes to prior authorization requirements
Visit our Formularies and Pharmacy Clinical Policy Bulletins page to view:

• Commercial pharmacy plan drug guides with new-to-market drugs we add monthly
• Clinical policy bulletins with the most current prior authorization requirements for each drug

Educational Opportunities Using Availity for Prior Authorizations and Claims Management

We’ll show you how to:

• Locate provider manuals, clinical policy bulletins and payment policies 
• Access online transactions such as those related to eligibility, benefits, precertifications and  claim status/disputes
• Register for live instructional webinars
• Access our online forms
• Navigate to our provider referral directory and Medicare directory
• Update your provider data, and much more

This course is offered on the second Tuesday and third Wednesday of each month from 1:00 PM to 2:15 PM EST. You can also visit our New Provider Welcome Page for additional resources to enhance your provider experience. 

Are You Confused About When to use Availity® Versus Aetna.com
Attend our Doing business with Aetna® — new provider onboarding webinar, which will cover this topic. The webinar is available to our existing providers and staff members on the second Tuesday and third Wednesday of each month from 1:00 PM to 2:15 PM EST.

Use Aetna® Preferred Labs for Breast Cancer Gene and Prenatal Testing
You can get automatic approvals in some cases.

Breast cancer gene testing
We’ve simplified your patients’ access to breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2) testing with Quest Diagnostics®. When you use Quest for services covered in our Clinical Policy Bulletin #0227, you’ll get automatic approvals for your commercial members.

Other Aetna national BRCA network labs:

• Labcorp
• BioReference Health, LLC/Genpath
• Ambry Genetics
• Baylor Miraca Genetics Laboratories, LLC
• Myriad Genetics, Inc.
• Medical Diagnostics Laboratories, LLC
• Invitae

Noninvasive prenatal testing (NIPT)
We’ve negotiated lower out-of-pocket NIPT rates with four preferred labs. That means you can now enjoy the convenience of working with labs you may have used before, help your patients save money and simplify your referral process.

Aetna’s national NIPT network:

• Quest Diagnostics 
• Labcorp
• BioReference Health, LLC/GenPath
• Invitae

Participating providers
For a complete list of our in-network participating providers, please use our provider search at Aetna.com.

How to Document Sepsis
Best documentation practices include being specific about the type of sepsis and test results.

Sepsis is a life-threatening medical emergency caused by the body’s overwhelming immune response to an infection and, as such, is seldom coded in the provider office setting.

Sepsis types

• Severe sepsis is sepsis with failure of one or more organ systems.
• In septic shock, there is a critical reduction in tissue perfusion and, despite intravascular volume replacement, the person remains hemodynamically unstable.
• Systemic inflammatory response syndrome (SIRS) is a condition where there is inflammation throughout the body that can lead to multiple organ failure and shock. Sepsis, trauma or pancreatitis can cause SIRS. Criteria for diagnosing SIRS are:
  • Temperature greater than 100.4 or less than 96.8
  • Heart rate greater than 90
  • Respiratory rate greater than 20
  • White blood cell count greater than 12,000 or less than 4,000

A person must meet two or more of the criteria to be diagnosed with SIRS.

Remember, no infection, no sepsis. Also, an infection that does not meet SIRS criteria is not sepsis.

Documentation
Best practice is to write out the condition in full followed by the abbreviation in parentheses the first time it is used. Subsequently, within the same note, you can use the abbreviation only.

Physical exam notes should include any current associated findings and diagnostic testing
results, including:

• Sepsis: The presence of (suspected or confirmed) infection with two or more of the SIRS criteria. Do not code sepsis unless these criteria are met. If the visit is for a follow up of previous sepsis, document the current infection being treated (C-Diff, pneumonia, UTI, etc.).
• Severe sepsis: Acute organ dysfunction or tissue hypoperfusion secondary to sepsis 
• Septic shock: Severe sepsis plus hypotension (systolic blood pressure less than 90) not reversed with fluid resuscitation, plus Mean Arterial Pressure (MAP) less than 65 or persistent lactic cidosis greater than or equal to 4

Assessment/Impression

• The term “sepsis” without any further description is classified as sepsis, unspecified. 
• If known, state the infectious agent (E. coli, fungal, viral, etc.) so that it can be correctly  classified.
• Document the etiology (pneumonia, UTI, decubitus ulcer, infected surgical site, etc.).
• When applicable, document any consequences of sepsis.

Treatment plan
The treatment plan should be as specific as possible and include items such as:

• Blood tests and other laboratory tests
• Imaging tests
• Medications, including antibiotics, IV fluids and vasopressors
• Supportive care (oxygen, dialysis, etc.)
• Referrals/Consultations

COVID-19 Public Health Emergency (PHE) Transition
Read on to find out about COVID-19 policy changes.

The U.S. Department of Health and Human Services announced in February 2023 that the COVID-19 PHE “emergency phase” would expire on May 11, 2023. This decision was based on COVID-19 trends.

Read about our COVID-19 policy changes. Scroll down the page to view “COVID-19 resources and support.”