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Aetna-NIA-SHBP SEHBP Updates
There has been much confusion and several instances of misinformation given by Aetna and NIA through the roll out of the new pre-authorization process administered by NIA.
Aetna and NIA put together a letter to address some of the concerns outstanding. The letter was sent via email to providers who had registered for any of the educational webinars NIA had held in Nov. and Dec. of 2018. As many of you did not register for you can read the letter here: Aetna-NIA Letter to Chiropractor .
Aetna and NIA had advised that to check if a patient needed pre-authorization or not the doctor should enter the patients information into the NIA site www.RadMD.com. If the patient showed in their system it meant that Aetna had loaded them there and that patient needed pre-auth. If they were not in the system, then they would not need pre-auth. Several issues arose. Lets review:
Denials for Lack of Pre-Auth: At the time when the system went live there were patients that were not loaded into NIA’s system by Aetna that did in fact need pre-auth. Therefore, many doctors checked the system, saw that the patient did not need pre-auth, proceeded with care and eventually received denials for lack of pre-auth. The letter encourages doctors to re-check their patients to make sure they have not been added to the NIA system since the initial roll out. For denials received under this scenario they advise to contact the dedicated Provider Relations Managers: Charmaine Everett Email: firstname.lastname@example.org Phone: 800-450-7281 x32615
Justin Clifford Email: email@example.com
SHBP/SEHBP Plans Requiring Pre-Auth: For the first several weeks of the year members reported that SHBP/SEHBP patients were showing in the NIA system, indicating they need pre-auth and this was confirmed by NIA and Aetna call centers. This was, for the most part, incorrect information. The SHBP/SEHBP Aetna Medicare Advantage plan members are in the NIA system because they will require pre-auth for care rendered by a PT or OT, but not chiropractic care. There is one exception to this statement. There is a small percentage of SHBP/SEHBP retirees who are on Aetna Medicare Advantage HMO plans. These patients were on this plan prior to the mass migration of the retirees to the Aetna Medicare Advantage plans for this year. These HMO plans only will require pre-auth and do only cover spinal manipulation. The patients with these plans should have ID cards marked as HMOs.
There is another group of SHBP/SEHBP patients that may require pre-auth. Townships and school districts can choose to either use the state run health plan or to set up their own plan for their active employees. Some townships and school districts have opted to set up their own plan with Aetna. Some of these are fully funded plans and hence will require pre-authorization. Aetna has stated that they cannot provide a list of townships or school districts in this situation. They note that the ID cards for these plans would not show the SHBP or SEHBP insignia despite the patient being a government worker. They will provide sample ID card photos to help identify teachers/municipal workers who fall into these categories. We will share these with membership once they are received.
Triad: Many members have reported receiving EOBs from Aetna with no payment stating that the claims were sent to Triad for processing. Some have even received letters from Triad confirming that the claims were received and would be processed soon! Let us re-confirm, Triad’s contract with Aetna ended Dec. 31st 2018 and no NJ chiropractic claims should be handled by Triad. I alerted Aetna of this issue. Aetna advised that this was a mistake and the issue had been corrected as of yesterday, Jan. 29. The claims that were sent to Triad are being sent back to Aetna to be processed. I have asked for a time frame on when these claims should be properly processed. We will advise once Aetna provides an estimated completion date.