Does Aetna follow CMS guidelines?
Aetna is complying with the CMS coding guidelines for COVID-19 lab testing.
Does Aetna follow the 8 minute rule?
Billing Non-Medical Insurances Before the 8-minute rule, SPM was how services were billed to all patients, including Medicare beneficiaries. SPM is stilled used with Blue Cross Blue Shield, Aetna, Cigna, auto insurances (Geico, State Farm, AllState) and Workman's Comp.
Does Aetna use Milliman or InterQual?
Some insurance companies (e.g., United, Aetna, Cigna, AvMed, Humana) use the Milliman language, while others (e.g., TRICARE, Blue Cross, Sunshine State) use the InterQual language.
What is Aetna precertification?
Precertification occurs before inpatient admissions and select ambulatory procedures and services. Precertification applies to: Procedures and services on the Aetna Participating Provider Precertification List. Procedures and services on the Aetna Behavioral Health Precertification List.
What is the 8-minute Medicare rule?
The 8-minute rule is a stipulation that allows you to bill Medicare insurance carries for one full unit if the service provided is between 8 and 22 minutes. As such, this can only apply to time-based CPT codes.
What is the AMA 8-minute rule?
The AMA uses similar guidelines as Medicare in that 1 unit equals 8 minutes. Where the AMA differs is that there is no cumulative restriction or adding of minutes, even for time-based codes. Every code will be allowed 1 unit for each 8 minutes performed.
What is the 2 midnight rule?
The Two-Midnight rule, adopted in October 2013 by the Centers for Medicare and Medicaid Services, states that more highly reimbursed inpatient payment is appropriate if care is expected to last at least two midnights; otherwise, observation stays should be used.
What is the difference between InterQual and Milliman?
InterQual's criteria are, in some respects, stricter than Milliman's, with more precise clinical benchmarks for each level of care. That could mean an uptick in denials for cases in which the patient is borderline for inpatient vs. observation or discharge vs. continued stay.
Does Medicare require InterQual?
Technically, Medicare does not specify or require Interqual or any other medical necessity screening criteria.
Is prior authorization required for Aetna?
Aetna Better Health® of California requires prior authorization for select acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services.
What is the difference between a prior authorization and a precertification?
Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
Does Aetna Medicare PPO require prior authorization?
For some services, your PCP is required to obtain prior authorization from Aetna Medicare. You'll need to get a referral from your PCP for covered, non‐emergency specialty or hospital care, except in an emergency and for certain direct‐access service.