Important information about our provider directory
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- Katrina Cunningham
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1 Important information about our provider directory This online directory provides a list of Aetna Medicare Plan (HMO) (PPO) network providers. To get detailed information about your health care coverage, please see your Evidence of Coverage. The online directory tool lets you search: For a provider by entering a ZIP code, county, or city By provider name, facility, specialty or condition For a hospital or urgent care center You may be required to select a product or plan name to complete the search. You can find a list of pharmacies that offer Part B and Part D drugs in your pharmacy directory. Check with your pharmacy to see if they offer the services you need to fill a prescription. Provider information contained in this directory is updated 6 days per week, excluding: Holidays and Sundays Interruptions due to system maintenance, upgrades or unplanned outages This information is subject to change at any time. So, please contact your provider before you schedule an appointment or receive services. Ask him or her to confirm that they are still participating in our network. To get the most up-to-date information about Aetna Medicare Plan (HMO) or (PPO) network providers in your area, call our Member Services department. Their number is (TTY: 711). They re available 8 a;m; to 8 p;m;, seven days a week. You can also get information from our website, Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. This information is available for free in other languages. Please call our Member Services number at (TTY: 711). Hours of operation: 8 a.m. to 8 p.m., local time, seven days a week, from October 1 February 14 and 8 a.m. to 8 p.m., local time, Monday Friday, from February 15 September 30. Esta información está disponible en
2 otros idiomas de manera gratuita. Comuníquese con Servicios al Cliente al (TTY: 711). Horario de atención: de 8 a.m. a 8 p.m., hora local, los siete días de la semana, del 1 de octubre al 14 de febrero, y de 8 a.m. a 8 p.m., hora local, de lunes a viernes, del 15 de febrero al 30 de septiembre. The HMO/PPO network providers listed in this directory have agreed to provide you with your health care services. You may go to any of our network providers listed in this directory; However, some services may require a referral; If you ve been going to one network provider, you re not required to continue going to that same provider; In some cases, you may get covered services from out-of-network providers. For some plans, you may have to choose one of our network providers to be your primary care physician (PCP). We use the term "PCP" throughout this directory. If a provider that is not part of our network sends you a bill, don t pay it; Instead, send it to!etna Medicare for processing; We ll determine your cost-sharing amount, if any. Certain network health care services, such as hospitalization or outpatient surgery, require prior authorization from Aetna Medicare. This means the service must be approved by Aetna Medicare before it will be covered under the plan. Check your Evidence of Coverage for a list of services that require this approval. When you are to obtain services that require prior authorization from a network provider, have him or her contact us. The provider is responsible to obtain prior authorization from Aetna Medicare before treatment. Some plans include an out-of-network benefit. If yours does and you decide to receive covered services from an out-of-network provider, we recommend you ask him or her to contact us for prior authorization of those services. Emergency care If you need emergency care, you re covered 24 hours a day, 7 days a week, anywhere in the world. Whether you are in or out of an Aetna Medicare service area, we simply ask that you follow the guidelines below when you believe you need emergency care. Call the local emergency hotline (for example, 911) or go to the nearest emergency facility. Notify your PCP as soon as possible after receiving treatment. Or if a delay would not be harmful to your health, call your PCP. If you re admitted to an inpatient facility, notify your PCP or Aetna Medicare as soon as possible.
3 If you re traveling outside of the!etna Medicare Plan (HMO) (PPO) service area, you re covered for emergency and urgently needed care; Emergency care can always be obtained in or out of the service area from the nearest available provider. When in the network service area, we require that HMO plan members use plan providers for urgent care unless the providers are not available. When out of the service area, you may obtain urgent care from the first available provider. You may obtain urgent care from a private practice physician, a walk-in clinic, an urgent care center or an emergency facility; We ll review the information submitted to us by the provider who supplied your care. If the nature of the urgent or emergency problem does not qualify for coverage, we may require additional information. Follow-up care after emergencies Your PCP should coordinate all follow-up care. For HMO plans, we may cover followup care with out-of-network providers only with both: A referral from your PCP Prior authorization from Aetna If your plan requires referrals, you must obtain a referral before we will cover any follow-up care. This applies whether you were treated inside or outside your Aetna Medicare service area. If your HMO plan does not require referrals you should contact our Member Services department before follow-up care is received at out-of-network facilities. You can reach them at (TTY: 711). Examples of follow-up care include: Suture removal Cast removal X-rays Clinic and emergency room revisits For PPO plans, we will cover in-network and out-of-network follow-up care after emergencies under the terms and conditions of your plan. CA members only: Aetna contracts with provider organizations called an Independent Practice Association (IPA) or Physician-Hospital Organization (PHO). An IPA/PHO is an
4 association of independent providers. It may include hospitals and primary care and specialist physicians who together provide health care services. Aetna uses several IPAs to provide health care services to members. If you choose a primary care provider (PCP) associated with an IPA/PHO, he/she will direct you to health care services within their IPA/PHO. This includes specialist care. If you re enrolled in our!etna Medicare Prime Plan (HMO) or (PPO), you have access to a network of local providers who we work closely with to coordinate your care. If you have the Prime HMO plan, you will have to pay on your own for out-of-network care. With the Prime PPO plan, we will pay for part of your out-of-network care but you may pay more out-of-pocket. If you need urgent or emergency care, or get out-of area kidney dialysis, we ll cover it; Even if the provider isn t part of the Prime network; If you are enrolled in our Aetna Medicare Prime Plan (HMO) or (PPO), you have access to a network of local providers who we work closely with you/each other to coordinate your care. If you are enrolled in a standard Aetna Medicare Plan (HMO), you ll have to choose a PCP. You can pick one of the network providers who are listed in this directory. Generally, you must get your health care coverage from your PCP. Your PCP will issue referrals to participating specialists and facilities for certain services. For some services, your PCP is required to obtain prior authorization from Aetna Medicare. Except in an emergency and for certain direct access services, you ll need to obtain a referral from your PCP before seeking covered non-emergency specialty or hospital care. There are exceptions for certain direct access services. You must use network providers except: In emergency or urgent care situations For out-of-area renal dialysis If you obtain routine care from out-of-network providers, Medicare and Aetna Medicare will not be responsible for the costs.
5 If you re enrolled in an!etna Medicare Plan (HMO) Open Access, you re not required to choose a PP; You re free to visit network providers without a referral to receive covered services.!lthough you re not required to select a PP, we encourage you to do so. You must use network providers except: In emergency or urgent care situations For out-of-area renal dialysis If you obtain care from out-of-network providers, your plan will not cover the charges. Medicare and Aetna Medicare will not be responsible for the costs. If you re enrolled in an!etna Medicare Plan (PPO), you have the flexibility to choose either network providers to receive covered services or out-of-network providers. With certain exceptions, it may cost PPO members more to get care from out-of network providers. Those exceptions include emergencies, urgent care and out-of network renal dialysis;!lthough you re not required to select a PP, we encourage you to do so. If you receive covered services from an out-of network provider, it is important to confirm they: Will accept your PPO plan Are eligible to receive Medicare payment What is the service area for the Aetna Medicare Plan (HMO) or (PPO)? Please see your Evidence of Coverage document for the most up to date service area listing. How do I find providers in my area? The online directory tool lets you search: For a provider by entering a ZIP code, county, or city By provider name, facility, specialty or condition For a hospital or urgent care center You may be required to select a product or plan name to complete the search. If you have questions about your Aetna Medicare Plan (HMO) (PPO) or need help selecting a PCP, call Member Services. Their number is (TTY: 711).
6 They are available 8 a.m. to 8 p.m., seven days a week. You can also obtain information on our website, Disclaimers See Evidence of Coverage for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. The provider network may change at any time. You will receive notice when necessary. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed. The provider network composition is subject to change. CA and NNJ Prime plan members only: Other pharmacies, physicians, providers are available in our network. Medicare!dvantage only plan members: ost sharing for members who get Extra Help is the same at preferred and network pharmacies; Aetna is committed to Accreditation by the National Committee for Quality Assurance (NCQA) as a means of demonstrating a commitment to continuous quality improvement and meeting customer expectations. You can find a complete listing of health plans and their NCQA status on the NCQA website. You can access the site at To refine your search, select Managed ehavioral Healthcare Organizations, in the drop down menu for behavioral health accreditation; Select redentials Verifications Organizations, for credentialing certification; lick on the link for Physicians and Physician Practices for physicians recognized by NQ! in the areas of:
7 Heart/stroke care Diabetes care Patient centered medical home and patient centered specialty practice The recognition programs are built on evidence-based, nationally recognized clinical standards of care. Therefore, NCQA provider recognition is subject to change. You can access the official NCQA directory of recognized clinicians at Aetna Inc. NR_0009_6366b 10/2015
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