National Care Management

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1 Natinal Care Management Subject Nn-Participating Prvider Plicy Review and Revised Dates: July 2004, September 2005, June 2006, June 2007, June 2008, March 2009, March 2010 Originating Department Natinal Care Management NCM Natinal Adptin Date: 03/08/10 Effective Date: 06/08/10 Signed riginal n file in Natinal Care Management Date: 3/8/10 Signature Authrity: James D. Crss, M.D. Applies t Department: PM Precertificatin NME WH BH DM IHL Prduct: HMO EPO PPO MC/POS TC Medicare Advantage (HMO) Type: New Revisin Replacement Review N changes Medicare Advantage (PPO) Medicare Advantage (PFFS) Related Materials: NCM NCM NCM NCM NCM NCM NCM NCM NCM NCM NCM NCM NCM Natinal Care Management Precertificatin Plicy Natinal Care Management Cncurrent Review and Discharge Planning Plicy Natinal Care Management Cncurrent Review and Discharge Planning Prcedure Natinal Care Management Medical Review Plicy Natinal Care Management Timeliness Standards fr Cverage Decisins and Ntificatin Prcedure Natinal Care Management Denial f Cverage Prcedure Natinal Care Management Peer-t-Peer Review Plicy Natinal Care Management Peer-t-Peer Review Prcedure Natinal Care Management Nn-Participating Prvider Prcedure Natinal Care Management Travel and Ldging Prcedure Natinal Care Management Medicare Advantage Out f Area Plicy Natinal Care Management Medicare Advantage Out f Area Prcedure Natinal Care Management Medicare Advantage U.S. Travel Advantage Prcedure Behaviral Health Outpatient Ad Hc Guide Perfrmance Supprt Tl at: Prvider Service Center Precertificatin Natinal Wrkflws: Nn-Participating Prvider Wrkflw at: Aetna Prduct Summary at: tnaprductsummary.xls Resurces: NCM Natinal Care Management Precertificatin Prcedure Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 1 f 11

2 Natinal Care Management NCM Nn-Participating Prvider Plicy NCM NCM NCM NCM NCM NCM NCM QM 10 Natinal Care Management Timeliness Standards fr Cverage Decisins and Ntificatin Plicy Natinal Care Management Medical Review Prcedure Natinal Care Management Denial f Cverage Plicy Natinal Care Management Travel and Ldging Plicy Natinal Care Management Transitin f Care Cverage Plicy Natinal Care Management Transitin f Care Cverage Prcedure Natinal Care Management Medicare Advantage U.S. Travel Advantage Plicy Natinal Quality Management and Measurement Plicy: Practitiner and Prvider Availability: Netwrk Cmpsitin and Cntracting Plan Behaviral Health Cntractr Standards Manuals at: Precertificatin Alternate Office Call (AOC) Handling & State Utilizatin Review (UR) Reference Tl at: Attachments: Nne Applicable Plicy Statements: A. General: A nn-participating prvider is defined as a physician, dentist, hspital, skilled nursing facility r ther individual r entity invlved in the delivery f health care r ancillary service that des nt have an agreement t participate in Aetna s netwrk and prvide cvered services t Aetna members. Cntractual agreements are prduct specific (e.g., a prvider may be cntracted fr all r a specific cmbinatin f Aetna prducts). Prviders wh are nt cntracted t participate with all Aetna prducts are identified as nnparticipating fr members enrlled in prducts that are nt included in the prvider s Aetna cntract (e.g., a prvider cntracted fr nly Open Chice [OC] members is cnsidered nnparticipating fr HMO members). Prviders are nly cntracted fr the Medicare Advantage prducts in the gegraphic areas in which the Medicare prducts are ffered. Aetna participating practitiners wh are nt designated fr inclusin within the identified Aexcel specialty categries (Nn-Designated Specialists) and Aetna participating practitiners wh pt ut f Aexcel are cnsidered nn-participating fr members enrlled in plans that include a cncentric Aexcel netwrk. Fr members enrlled in plans that include a cncentric Aexcel netwrk, a request fr cverage 1 f cvered services t be rendered by a Nn-Designated Specialist r a nnparticipating prvider requires precertificatin in rder t be eligible fr payment. 1 Fr these purpses, "cverage" means either the determinatin f (i) whether r nt the particular service r treatment is a cvered benefit pursuant t the terms f the particular member's benefits plan, r (ii) where a prvider is required t cmply with Aetna's utilizatin management prgrams, whether r nt the particular service r treatment is payable under the terms f the prvider agreement. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 2 f 11

3 Natinal Care Management NCM Nn-Participating Prvider Plicy Aetna participating practitiners wh are nt designated fr inclusin within the identified Aexcel specialty categries and practitiners wh pt ut f Aexcel are cnsidered participating fr plans that include a multi-tiered Aexcel Plus netwrk hwever; members are respnsible fr higher cst sharing amunts when accessing these practitiners. These same principles apply t members enrlled in a multi-tiered specific plan/hme hst Integrated Delivery System (IDS) netwrk; use f an Aetna participating prvider nt included in the IDS netwrk results in additinal member financial respnsibility. Fr members enrlled in a plan that includes a multi-tiered Aexcel Plus r IDS netwrk, requests fr cverage f cvered services t be rendered by a nn-participating prvider requires precertificatin in rder t be eligible fr payment at an in-netwrk benefit level (des nt apply t OC plans). If apprved, the in-netwrk benefit level is nt equivalent t the Aexcel practitiner/ids prvider benefit as there is n prvisin fr cverage f services rendered by a nn-participating specialist/prvider at the highest level f benefits in either an Aexcel Plus plan r an IDS plan. Members enrlled in Medicare Advantage plans wh electively access a nn-participating prvider wh has either pted ut f Medicare r wh has been debarred/sanctined are financially respnsible fr all services. Fr emergency services, nn-participating prviders wh have pted ut f Medicare are eligible fr cverage. Members enrlled in plans that d nt require a primary care physician (PCP) selectin may access cvered services at the in-netwrk level f benefits frm any cntracted prvider. Alternatively, members enrlled in plans that require a PCP selectin may access cvered services at the in-netwrk level f benefits frm any cntracted prvider with a valid PCP referral. The nly exceptin t this referral requirement is that behaviral health services d nt require a PCP referral. Fr members enrlled in a plan that includes a multi-tiered Aexcel Plus/IDS netwrk, the presence f a referral frm a member s PCP t a practitiner nt included in the Aexcel specialty netwrk r a prvider nt included in a plan specific/hme hst netwrk des nt impact the level f benefits applied t a claim. Referrals and in-netwrk benefits, as applicable, are nt limited t a specific gegraphical area (unless required by state law r regulatin) but rather are determined by the cntractual terms f a prvider agreement. Fr example, if a Massachusetts prvider is cntracted fr the HMO prduct, then a New Jersey HMO member may access that Massachusetts participating prvider with a PCP referral. Tw exceptins exist t the applicability f this plan specificatin fr referrals/in-netwrk benefits: The Aetna Federal Gvernment HMO plan (Federal Emplyee Health Benefits Prgram [FEHBP]) limits in-netwrk benefits fr rutine care t a specific gegraphic service area. Medicare Advantage HMO members are limited t receiving in-netwrk care within the defined service area, r a cntiguus area, except fr emergency care r urgent care. The exceptin t the rutine access rule fr Medicare Advantage HMO members wh are temprarily ut f the service area is that renal dialysis is eligible fr cverage when services are received frm a Medicare qualified dialysis prvider. In additin, Medicare Advantage HMO members, while enrlled in the Travel Advantage Prgram may access cvered services when utside the riginal assigned service area fllwing (NCM ) Natinal Care Management Medicare Advantage U.S. Travel Advantage Plicy. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 3 f 11

4 Natinal Care Management NCM Nn-Participating Prvider Plicy This plicy des nt apply t the fllwing nn-participating prvider requests; separate guidelines reflective f the unique nature f these situatins have been develped and are therefre utside the scpe f this dcument: Requests fr members underging an active curse f treatment at the time f enrllment/reenrllment r at the time an Aetna participating prvider terminates their Aetna cntract are handled fllwing (NCM & 02) Natinal Care Management Transitin f Care Cverage Plicy and Prcedure. Requests fr behaviral health cverage managed by a delegated behaviral health cntractr are handled (as applicable) fllwing the Behaviral Health Cntractr Standards Manual. B. Health Plan and Prduct Applicability: Aetna maintains a brad netwrk f participating PCPs, specialists and facilities within each defined service area. Netwrk adequacy is defined by prduct and by market and is mnitred and cnfirmed by Netwrk and Quality Management thrugh Ge Access reprts. Standards fr prvider availability are set frth fllwing (QM 10) Natinal Quality Management and Measurement Plicy: Practitiner and Prvider Availability: Netwrk Cmpsitin and Cntracting Plan and are in cmpliance with accreditatin standards and applicable state and federal laws and regulatins. Sites with Medicare cntracts incrprate a standard f thirty (30) minutes drive time mdified t meet patterns f care. Plans that include Aexcel r IDS netwrks are subject t the applicable plan netwrk specificatins. 1. HMO, HMO Open Access, Elect Chice and Elect Chice Open Access Plans: These Aetna plans generally d nt prvide benefits fr services rendered by nn-participating prviders except fr emergency r ut f area urgent care. Requests fr cverage f elective nn-behaviral health services frm a nn-participating prvider must be submitted by the PCP r the referring participating prvider with the exceptin f Open Access plans fr which members may initiate a nn-participating prvider cverage request. Elective nn-participating behaviral health cverage requests may be submitted by the member, by the treating prvider (participating r nn-participating), r by the PCP. Members wh have been seen electively by a nn-participating prvider withut prir apprval are ntified that cverage is denied, which may include all services and facility charges. 2. Quality Pint f Service (QPOS), Managed Chice (MC), and MC Open Access: These Aetna plans include an ut-f-netwrk benefit cmpnent that prvides payment f cvered services rendered by nn-participating r nn-preferred prviders. Generally, ut-f-netwrk benefits are subject t higher cst sharing thrugh deductibles and cinsurance. Members r prviders may initiate a nn-participating prvider cverage request fr in-netwrk benefits. If services are prvided by a nn-participating prvider withut prir apprval at the innetwrk level f benefits, the claim is paid accrding t the plan benefit structure. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 4 f 11

5 Natinal Care Management NCM Nn-Participating Prvider Plicy 3. Medicare Advantage HMO, Medicare Advantage HMO Open Access, Medicare Advantage PPO: Members and prviders (bth cntracted and nn-cntracted) may submit a pre-service cverage request fr an expedited r standard rganizatin determinatin. Medicare Advantage HMO and HMO Open Access members wh electively access a nnparticipating prvider withut prir apprval at the in-netwrk level f benefits are ntified that cverage is denied, which may include all services and facility charges. Medicare Advantage PPO members may electively access a nn-participating prvider withut a referral r prir authrizatin. In these instances, the member is respnsible fr higher ut-fpcket cst sharing. Claim payment fr nn-participating prvider services at the in-netwrk level f benefits is subject t precertificatin. Nn-participating prviders wh d nt accept Medicare assignment may be accessed electively by Medicare Advantage PPO members and may be apprved during the precertificatin prcess fr Medicare Advantage HMO and PPO members fr cverage at the in-netwrk level f benefits. 4. Traditinal Chice (TC), Open Chice (OC), Medicare Advantage Private Fee-fr-Service (PFFS): The Nn-Participating Prvider plicy des nt apply t Traditinal Chice, Open Chice r Medicare Advantage Private Fee-fr-Service plans. Traditinal Chice (TC) and Medicare Advantage Private Fee-fr-Service (PFFS) plans d nt include a prvider netwrk. Claim payment is based upn cvered services, which are subject t a deductible and cinsurance. Open Chice (OC) plans d nt require a referral fr specialty care. There are generally three (3) levels f claim payment available based upn whether the cvered service was sught frm a participating prvider (preferred prvider), nn-participating prvider (nn-preferred prvider), r thrugh a nn-participating prvider because netwrk adequacy did nt allw fr cverage thrugh a participating prvider (ther care). The pint f cntact fr OC members requesting nn-participating prvider reimbursement at the preferred r ther benefit level based upn netwrk adequacy is thrugh Aetna Member Services (nn-behaviral health services) r Aetna Behaviral Health Custmer Service (behaviral health services). The Member/Custmer Services staff prcesses these requests with cnsultatin as needed frm Netwrk Management fr nn-behaviral health services r frm Behaviral Health Care Managers fr behaviral health services. C. Decisin Making: The Aetna Participating Prvider Precertificatin List and the Behaviral Health Precertificatin List identify services that require precertificatin by participating prviders. 1. Precertificatin: Payment f services rendered by nn-participating prviders at the in-netwrk level f benefits fr plans that include ut-f-netwrk benefits (e.g., QPOS, Medicare Advantage PPO, MC Open Access, and MC) r under benefit plans that d nt include ut-f-netwrk benefits (e.g., HMO, EC, Medicare Advantage HMO) are eligible fr cnsideratin thrugh the precertificatin prcess when the cverage request is received prir t the date f service. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 5 f 11

6 Natinal Care Management NCM Nn-Participating Prvider Plicy Members enrlled in plans that include a multi-tiered netwrk (e.g., Aexcel r IDS) have a level f payment determinatin applied t submitted claims based upn whether services were received frm an Aexcel designated practitiner r a prvider included within the IDS netwrk; an Aetna participating practitiner r prvider (nt included in the Aexcel specialty categries r the plan specific hme hst IDS netwrk); r a nn-participating practitiner/prvider. a. Elements f Decisin: Precertificatin f services fr nn-participating prviders at the in-netwrk level f benefits includes Aetna physician Medical Directr/psychiatrist/psychlgist 2 review (except as nted belw) and a determinatin that the requested service cannt be prvided within the market defined access standard. An exceptin t the use f the market access standard may be made fr requested cverage with a nn-participating prvider utside f the market access standard. In this case, the travel distance fr the requested nn-participating prvider is substituted as the standard against which the availability f the participating prvider is based. (Fr example, if the cverage request is fr use f a nn-participating prvider 75 miles frm the member s hme, and the market access standard is 30 miles, then the availability f a participating prvider 75 miles frm the member s hme [rather than the market access standard f 30 miles] is evaluated as part f the nn-participating prvider cverage request prcess.) State mandates fr minimum and/r maximum requirements supersede the market defined access standards. Patient Management/Precertificatin/Behaviral Health/Natinal Medical Excellence and Wmen s Health staff 3 dcument cnfirmatin in etums f the names f the identified participating prviders wh are accepting new patients and wh can treat the member s cnditin as part f the cverage request review prcess. Situatins that may be authrized withut Aetna physician Medical Directr/psychiatrist/psychlgist review include, but are nt limited t: Fllw-up t initial Emergency Rm (ER) treatment by an ER physician r specialist as indicated by ER discharge instructins (e.g., evaluatin f a nn-displaced fracture by a nnparticipating rthpedist 2 weeks pst ER casting); Fllw-up t emergency surgery perfrmed within the previus 90 days; Legislatively mandated cverage; Knwn netwrk gaps dcumented by n-line systems (e.g., Dc Find, Aetna Strategic Desktp [ASD]) r anther resurce such as the state specific Precertificatin AOC & State UR Reference Tl Knwn Netwrk Deficiency Tip Sheet that leads t a definitive cnclusin that a participating prvider wh can evaluate and treat the member s cnditin is nt available; Behaviral health cverage requests that the Care Manager Supervisr determines t be medically necessary, unique r highly specialized. 2 A licensed psychlgist reviews cverage requests that are within the psychlgist s scpe f practice and fr which the psychlgist s clinical experience prvides sufficient experience t review the request. A licensed psychlgist des nt review cverage requests fr inpatient care and/r prescriptin medicatins unless state regulatins permit. 3 Staff is defined thrughut this plicy as Aetna Patient Management, Precertificatin, Behaviral Health, Natinal Medical Excellence and Wmen s Health emplyees. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 6 f 11

7 Natinal Care Management NCM Nn-Participating Prvider Plicy Elements cnsidered during the review prcess fr requests fr in-netwrk benefits fr services rendered by nn-participating prviders include, but are nt limited t: The infrmatin submitted thrugh the precertificatin prcess with the supprting ratinale fr the request; Requests fr additinal infrmatin required fr decisin making are handled fllwing the prcesses and time frames identified in (NCM ) Natinal Care Management Precertificatin Prcedure and (NCM ) Natinal Care Management Timeliness Standards fr Cverage Decisins and Ntificatin Plicy. A review f plan dcuments t determine whether the requested service is a cvered benefit; Requests fr specifically excluded benefits r limited benefits that have been exhausted are handled as administrative denials. A determinatin as t whether the service is medically necessary based upn Aetna apprved criteria/guidelines and is unique r highly specialized and is nt therwise available frm a participating prvider r the available participating prvider falls utside f designated market access standards. Fr behaviral health cverage requests, this determinatin is the respnsibility f the Care Manager Supervisr unless the cverage request is nt able t be apprved. If the Care Manager Supervisr is unable t apprve the cverage request, a referral is initiated t an Aetna physician Medical Directr/psychiatrist r psychlgist fr a cverage determinatin. Fr nn-behaviral health cverage requests, this determinatin is made (as apprpriate) by Aetna physician Medical Directr. Fr all cverage requests, utreach is cnducted and/r utreach infrmatin is utilized that has been btained by ther staff abut alternative netwrk prviders cnfirming that the alternative prvider can evaluate and treat the member s cnditin. Outreach methdlgies may include but are nt limited t: A direct cnversatin with the PCP r referring prvider t include an explanatin that cverage wuld be available fr a secnd pinin with an alternative netwrk prvider; A direct cnversatin with the nn-participating prvider t include an explanatin f the prpsed treatment; Sending clinical infrmatin t the alternative netwrk prvider fr review (absent any member identifying infrmatin); Having the alternative netwrk prvider speak directly t the nn-participating prvider; Any cmbinatin f these appraches. Fr chrnic renal hemdialysis nly, Aetna physician Medical Directr review f available infrmatin may cnfirm that althugh participating prviders exist within the netwrk, a temprary netwrk deficiency exists based upn capacity issues that preclude the member frm temprarily receiving services within the netwrk. In these instances, the member is ntified f all f the fllwing: The nn-participating prvider authrizatin is valid fr sixty (60) days; Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 7 f 11

8 Natinal Care Management NCM Nn-Participating Prvider Plicy The name f the participating facility that the member will access hemdialysis services frm when available; and, The fact that anther nn-par referral is required fr services beynd the date initially authrized. In these instances, Netwrk Management is ntified f the identified access issue fr cnsideratin f additinal netwrk cntracting pprtunities. In additin, when applicable, the Single Case Cntracting Unit (SCCU) r Netwrk Management is ntified fr ptential fee negtiatins. 4 (Refer t Once the determinatin has been made that the requested service is nt specifically excluded r in the case f a limited benefit, that the benefit is nt exhausted, the nn-participating prvider cverage request is referred t the Aetna physician Medical Directr r BH Care Manager Supervisr t determine whether the requested service shuld be cnsidered as a cvered benefit at the in-netwrk benefit level. Fr behaviral health cverage requests, if there is a participating prvider available, the nnparticipating prvider cverage request is referred t the BH Care Manager Supervisr. If the BH Care Manager Supervisr is unable t apprve the cverage request, a referral t an Aetna physician Medical Directr/psychiatrist/psychlgist is initiated. The Aetna physician Medical Directr/psychiatrist/psychlgist uses the clinical review prcess t determine whether the available participating prviders have the apprpriate clinical expertise t treat the member s cnditin r t prvide the requested prcedure/service. Aetna participating specialty prviders are identified based upn the specialty categry fr which a bard certificatin exists. Bard certificatin categries are listed at: American Bard f Medical Specialties: Specialties & Subspecialties. Similar specialty is cnsidered the American Bard categry. The additinal listed certificates are referred t as subspecialties. An Aetna subspecialty participating prvider match is nt required unless specified by the Aetna physician Medical Directr/psychiatrist/psychlgist. If the request is fr in-netwrk benefits fr treatment r cnsultatin by a nn-participating prvider (whether r nt a specific prcedure/service was requested) when treatment is available fr the member s cnditin frm a participating prvider, then the in-netwrk benefit determinatin is cnsidered t be a clinical determinatin. Fr example, a nn-participating prvider cverage request (at an in-netwrk benefit level) is specifically fr a chlecystectmy by laser technique. It is determined that this prcedure is a cvered benefit, yet there is nt a participating prvider that perfrms this prcedure. As part f the review prcess, it is determined that chlecystectmy by laser is nt superir r is generally equivalent t chlecystectmy by ther means. The cverage request fr innetwrk benefits is denied as there are participating prviders available t treat this member's cnditin (gallbladder disease requiring chlecystectmy). If an ut-f-netwrk benefit level is available under the member's plan, then the specific prcedure/service wuld be cvered at that benefit level. [Nte: Had it been determined upn clinical review that the specific requested prcedure/service (e.g., chlecystectmy by laser) was superir and medically necessary, then an in-netwrk benefit cverage apprval determinatin wuld be made due t netwrk inadequacy.] 4 SCCU and Netwrk referrals are nt initiated fr Medicare Advantage members. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 8 f 11

9 Natinal Care Management NCM Nn-Participating Prvider Plicy If the nn-participating prvider cverage request (at an in-netwrk benefit level) is fr the treatment f gallbladder disease r chlecystectmy (by any technique), the cverage request is denied as there are participating prviders available t treat this member's cnditin (gallbladder disease requiring chlecystectmy). b. Additinal Cnsideratins: When reviewing a request fr in-netwrk benefits fr nn-emergency services by a nn-participating prvider, the member s stability fr travel, a determinatin whether a participating prvider is available within the market access standard r in gegraphic prximity t the member s service area and any applicable state r federal requirements are included as part f the cverage determinatin prcess. Members may be eligible fr cnsideratin f travel and ldging reimbursement when participating prvider services are authrized utside f the service area and the member meets the cnditins utlined in (NCM ) Natinal Care Management Travel and Ldging Plicy. 5 In additin t prvider participatin status and travel distance, when reviewing requests fr in-netwrk benefits fr nn-emergency services by nn-participating prviders, cnsideratin is given t the fllwing factrs: Cntinuity f care; Crdinatin f fllw-up services by participating prviders; Transfer t participating prviders within the service area as sn as clinically feasible. 2. Inpatient Review: The standard level f inpatient review fr members hspitalized within nn-participating facilities is cncurrent review with discharge planning. The nly exceptin t this review standard is fr members enrlled in Medicare Advantage plans wh are fllwed fr discharge planning nly. When applicable, inpatient care that des nt meet cverage criteria is referred t an Aetna physician Medical Directr/psychiatrist/psychlgist fr review. When the member s cnditin is stable, if apprpriate, there is crdinatin by the PCP (as applicable based upn the plan type when the member is receiving inpatient medical services; PCP invlvement is nt required fr behaviral health services), the Care Management Team, and the attending physician t facilitate transfer t a participating facility. Fr members enrlled in plans where a PCP is required but wh have nt yet designated a PCP, fr behaviral health services, r when the PCP is unwilling t assist with crdinatin f the transfer, the Care Management Team facilitates the transfer, as apprpriate, with the attending physician and receiving prvider. Fr HMO, Medicare Advantage HMO and EC members, benefits fr services rendered by nn-participating prviders are available nly fr the emergency and stabilizatin phase f treatment. Additinally, fr Medicare Advantage members, in-netwrk benefits fr services rendered by a nn-participating prvider may be available fr pst-stabilizatin services fllwing emergency treatment in the fllwing circumstances: If the services requested by the member r prvider are authrized by the health plan; r, 5 The travel and ldging allwance is nt available fr behaviral health services. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 9 f 11

10 Natinal Care Management NCM Nn-Participating Prvider Plicy If the health plan fails t respnd within ne (1) hur frm receipt f the cverage request, the services are payable until alternative arrangements are made fr discharge r transfer. D. Ntificatin f Determinatin: Ntificatin f the nn-participating prvider cverage determinatin includes all elements f the request: bth chice f prvider and eligibility f the requested service. When clinical infrmatin is included with the cverage request, clinical guidelines/criteria are applied and are cnsidered as part f the determinatin fllwing (NCM ) Natinal Care Management Medical Review Prcedure. Adverse cverage determinatins are cmmunicated in writing fllwing established prcesses and may include faxed ntificatin fr cncurrent review decisins t the member r member authrized representative 6 as nted in (NCM ) Natinal Care Management Denial f Cverage Plicy. Written ntificatin f adverse determinatins fr elective nn-participating prvider innetwrk benefit cverage requests includes: Ntice that claim payment will be denied fr plans withut ut-f-netwrk benefits r that payment will be prcessed at the ut-f-netwrk benefit level fr plans that include utf-netwrk benefits; and, The names and phne numbers f the alternative participating prviders wh have cnfirmed that they are able t evaluate and treat the member s cnditin. Cverage apprval fr services rendered by a nn-participating prvider is cmmunicated verbally and, when mandated r requested, in writing. Written cverage apprval determinatin letters include: The identificatin f the services fr which cverage is authrized; The time perid fr the authrizatin; and, The requirement t utilize participating prviders fr any additinal services nt cvered under the authrizatin r the cverage fr thse services will be denied. When nn-participating prvider services are authrized, a referral t SCCU fr ptential fee negtiatin is initiated as applicable 7 fllwing the guidelines at: Prviders that participate in the Natinal Advantage Prgram (NAP) are nn-participating and with the exceptin f dialysis centers that participate in NAP, are nt referred t SCCU fr fee negtiatin. 6 Fr precertificatin, cncurrent and retrspective reviews, an individual must satisfy at least ne f the fllwing requirements in rder t be cnsidered an Authrized Representative f a member: The member has given express written r verbal cnsent fr the individual t represent the member's interests. A member can appint an attrney t represent them. The individual is authrized by law t prvide substituted cnsent fr a member (e.g.-parent f a minr, legal guardian, fster parent, pwer f attrney); r Fr pre-service, urgent care r cncurrent claims nly, the individual is an immediate family member f the member (e.g.- spuse, parent, child, sibling); r Fr pre-service, urgent care r cncurrent care claims nly, the individual is a primary caregiver f the member; r Fr pre-service, urgent care r urgent cncurrent care claims nly, the individual is a health care prfessinal with knwledge f the member's medical cnditin (e.g. - the treating physician). 7 SCCU and Netwrk referrals are nt initiated fr Medicare Advantage members. Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 10 f 11

11 Natinal Care Management NCM Nn-Participating Prvider Plicy Nn-participating behaviral health utpatient practitiner services (e.g., ffice visits) apprved at the preferred benefit level are asked t sign a Letter f Agreement which specifics services and fees which have been agreed t and will be reimbursed. Peridic reprts f nn-participating behaviral health practitiners wh enter int single case agreements are prvided t Behaviral Health Netwrk staff fr utreach and ptential cntracting pprtunities. Mre stringent state requirements may supersede these requirements. Apprval t Implement: Reginal Quality Oversight Cmmittee Chairpersn (r designee): Michael Mesras, MD 04/28/10 Signature Date Aetna is the brand name used fr prducts and services prvided by ne r mre f the Aetna grup f cmpanies. (Aetna) March 2010 Fr Aetna Use Only Page 11 f 11

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