May/June 2005 - Center Care Health Benefits Programs

NORTH CENTRAL REGION MAY/JUNE 2005 

Aetna 

Office 

Updates 

ISSUE 3, VOLUME 2 

Link 

Inside This Issue 

Let’s Talk About . . . . . . . . . . . . . . . . . . 2 

Working Together . . . . . . . . . . . . . . 3-4 

OfficeWise. . . . . . . . . . . . . . . . . . . . . 5-7 

Policy & Practice Updates . . . . . . . . 8-9 

Striving for Quality Excellence . . . . 10 

Specialties in Practice . . . . . . . . . 11-12 

Plan Facts & Features. . . . . . . . . . 13-14 

In Your Area. . . . . . . . . . . . . . . . . . . . 15 

The Importance of Discussing Advance Directives With Your Patients 

Talking with your patients about the type of care they may want, should they 

be faced with an illness or accident, is not an easy discussion. But when a 

patient decides to fill out an advance directive* form, you are in a unique 

position to give your patient high-quality care, while keeping that individual’s 

end-of-life needs in mind. 

Completing an advance directive form 

demonstrates that your patients have 

put time and thought into the type of 

medical treatment they may or may 

not want, and this should assist others, 

including physicians and loved ones, 

in carrying out their wishes. The 

advance directive also gives patients 

peace of mind that their medical care 

will be handled in the manner they 

have requested. 

Aetna’s Compassionate Care 

website is designed as a “resource 

center” to help you and your 

patients better understand the 

issues and choices associated 

with end-of-life care. The website 

includes helpful information on 

end-of-life and palliative (comfort) 

care issues, advance planning tools, 

tips to begin conversations with 

loved ones on advance directive 

forms and living wills. 

www.aetnacompassionatecare.com 

Some states require specific advance directive forms; others allow generic or 

homemade documents. You or your patients can call the National Hospice and 

Palliative Care Organization at 1-800-989-9455 for an advance directive form 

or for additional information. 

* Centers for Medicare & Medicaid Services (CMS) requires that information on Advance 

Directives be documented in your Medicare patients’ charts. 

Tips for discussing advance 

directives with your patients 

■ Create a questionnaire regarding 

advance directives to accompany 

the standard documents (for 

example, HIPPA forms) your 

patient fills out when visiting 

your office. Or add a question 

to your patient intake form 

requesting the status of your 

patient’s advance directive. 

■ If your patient doesn’t have 

an advance directive, provide 

a website link and/or telephone 

number for accessing statespecific 

advance directive forms. 

■ Encourage patients to provide 

you with a copy of their advance 

directive to be included in their 

medical chart; explain that this 

will ensure they receive the type 

of medical care they have 

requested should they become 

ill or have an accident. 

■ Develop a standard practice 

of having a conversation about 

advance directives at your 

patient’s annual check-up visit. 

23.22.807.1-NC (5/05)

Let’s Talk About… 

Communicating With Older Patients and 

Their Families: New Tools and Resources 

A newly revised guide entitled Working 

with Your Older Patient: A Clinician’s 

Handbook is now available free from 

the National Institute of Aging. 

The publication targets physicians, 

nurses, physician assistants and other 

health professionals who want to 

improve relationships and bridge 

communication gaps with their older 

patients. The comprehensive 52-page 

booklet delves into critical topics such 

as prevention and wellness, driving, 

incontinence, sexuality, supporting 

patients with chronic conditions and 

end-of-life care. The guide also 

provides successful communication 

strategies to discuss issues such as 

breaking bad news, cognitive 

problems, sensitive subjects, families 

and caregivers, and working with 

diverse older patients. 

Valuable timesaving tools are included 

in the guide as well. A tear-off card in 

the back of the booklet provides details 

on a range of services and resources 

from elder care to Meals on Wheels. 

Order your free copy by calling 

1-800-222-2225 or view the guide 

online at www.niapublications.org/ 

pubs/clinicians2004/index.asp. 

Communication Tools for the 

Older Patient 

The AARP website features helpful 

tips for senior patients regarding 

communicating with physicians. 

Direct patients to www.aarp.org/ 

health/healthguide and under 

“Quality Matters,” they can choose 

“Make the Most of Doctor’s Visits.” 

Here they may download specific 

forms to construct their medical 

history, document complaints, record 

medications and more. Seniors are 

encouraged to fill out the forms prior 

to their appointments to make the 

most of their time with the physician. 

Resources for Family 

and Caregivers 

The Administration of Aging website 

features “The National Family 

Caregiver Support Program Resource 

Room” (www.aoa.gov/prof/ 

aoaprog/caregiver/caregiver.asp). 

Featuring separate content for family 

caregivers and professional providers, 

the resource room is available in nine 

languages (English, Chinese, French, 

German, Italian, Japanese, Korean, 

Portuguese and Spanish) making it 

especially helpful for families whose 

primary language is not English. In the 

resource room, a caregiver can find 

local services, governmental resources, 

tips for providing good care and 

support groups. 

Aetna OfficeLink 

Updates Wins Dalton 

Pen Communications 

Award 

Your physician and office staff 

newsletter, Aetna OfficeLink 

Updates, was presented with an 

Award of Honor in the 2005 

Dalton Pen Awards competition. 

A year ago, this newsletter was 

redesigned and transformed to 

better serve you, based on your 

direction. Both the content and 

appearance of the newsletter have 

been revitalized to make it a more 

meaningful, effective publication 

for you. Thank you for your 

continuing feedback. 

The Dalton Pen Communications 

International Awards Program is 

sponsored by Warwick Publishing 

and recognizes outstanding projects 

in the communications field. 

2 Aetna OfficeLink Updates

Working Together 

Aetna Service Options for Health Care Professionals SM 

What’s New on the Secure Website 

Claims 

■ Updated Clinical Policy Code Lookup tables, Code Editing Tools and 

Aetna-specific code logic; changes and additions to Payment and Coding 

Policies; added Medical Necessity Denials link to Policy Information section; 

updated Benefit Guidance Statements 

Precertification 

■ Added a printer-friendly version of 2005 Medical Precertification List 

Referrals 

■ Updated Automatic Studies list; added notification of address change 

for submitting paper referrals 

Pharmacy 

■ Under Participating Pharmacy Lookup, updated Aetna Specialty Pharmacy SM 

information 

Doing Business With Aetna 

■ Updated Physician Advisory Board link 

—Additional Information section – added Strategic Resource 

Company (SRC) – Provider Q & A 

—Newsletters: Added March/April 2005 OfficeLink Updates newsletters; 

added CA e.BRIEF IPA/Physician Group Newsletter 

—Mailings: Aetna Select (North Central Region/KS and MO only); 

FL Medicare bulletin; PA Physical Therapy Cap Program letters 

Clinical Resources 

■ Updated Health Education Materials For Your Patients 

■ Added Adult Treatment Panel III (ATP III) Cholesterol Management 

Implementation Tool for Palm Operating System (OS) ® 

—Additional Information section – added link to Aetna Compassionate 

Care SM Program 

■ Updated Clinical Resources for Physicians and Their Patients page 

CME & Office Staff Training 

■ CME: Added new Colorectal Cancer CME 

■ 

Office Staff Training: Added text versions of National Advantage Program 

and Member ID Card courses; updated ERA/EFT forms and contact list in 

ERA/EFT course 

Skip the Zip — Aetna 

Voice Advantage ® 

is Now Quicker 

and Easier to Use 

When calling our self-service, 

interactive voice response phone 

system to check claim status or 

coverage and benefits for PPO and 

indemnity members, you no longer 

need to supply your Aetna patient’s 

zip code when you identify your 

practice using your tax ID number. 

Simply use the member’s ID that 

begins with a “W” followed by all 

numbers, or the primary plan 

member’s Social Security number, 

provide the patient’s date of birth 

and skip the zip! 

Aetna OfficeLink Updates 3

We’re Strengthening Our Protection of Member Health and Financial Information 

Via Encrypted E-mail 

We are further strengthening our protection of member 

health and financial information through the use of 

encrypted e-mail. In mid-April, we began encrypting all 

Internet e-mails sent to third parties, including physicians, 

that contain member-specific health and financial 

information. 

■ Examples of member-specific information include 

personal and demographic information (such as name, 

Social Security number and address), employment 

information, information about payment of benefits, 

provider information, diagnostic or treatment 

information, claims status information and information 

related to behavioral health and/or sexually transmitted 

disease services. 

Secure Website Spotlight 

Submit Precertifications Online 

Now more user-friendly, our online Precertification 

Tools are designed to help you save time and make 

doing business with us easy. Just click on “Precertification” 

on the home page of the secure website to access these 

convenient features: 

■ Add and Inquire on the status of electronic 

precertifications for: 

— Admission Review 

— General/Outpatient Services 

— Ambulance 

— Durable Medical Equipment 

■ Receive an immediate response on the status 

of a submitted precertification 

■ 

■ 

■ 

■ 

Encrypted e-mail will enable us to send quick, 

reliable communications while maintaining our 

commitment to protecting the confidentiality of 

member-specific information. 

Encrypted e-mail is scrambled by the sender’s e-mail 

program, which renders it unreadable until it is 

descrambled or “decrypted” by the recipient. 

Each encrypted e-mail from us will include a message 

indicating that the content has been secured via 

encryption, as well as instructions on how to open the 

message and view the secure content. 

You will be able to send an encrypted e-mail to us via 

the home page of our website www.aetna.com: 

1. Click on “Contact Us” in the upper right corner, or 

2. Log in to the secure website and then click on 

“Contact Us” in the upper right corner. 

■ Available for: 

— Primary care physicians, specialists, facilities, 

ancillary providers and suppliers 

— All Aetna benefits plans, including HMO-based, 

PPO-based and indemnity plans 

■ Requires minimal data entry 

■ Includes a customizable address book for providers’ IDs 

■ Access to precertification policy as well as up-to-date 

medical and prescription precertification lists 

The secure website for physicians, hospitals and health care 

professionals also offers eligibility verification, and claims 

and referral transactions. Visit our site at www.aetna.com 

and see how easy online precertification submission can be. 

Eligibility and Benefits 

The Eligibility/Benefits feature of our secure website 

provides free tools and information to verify real-time 

patient eligibility and benefits at the touch of a mouse. 

This electronic real-time eligibility (RTE) transaction 

enables physicians and hospitals to request patient 

eligibility status through electronic data interchange (EDI). 

Highlights include availability: 

■ For all Aetna benefits plans, including HMO- and 

PPO-based plans (both medical and dental) 

■ 24 hours per day, 7 days a week for your convenience 

■ For primary care physicians, specialists, ancillary 

providers and vendors 

Our website includes easy to use transaction screens and 

help documents such as a Member ID Card overview and 

electronic eligibility overview and Q&A. We’ve also 

provided an EDI Savings Calculation Worksheet, which 

can assist your office in determining potential savings in 

connecting to Aetna electronically versus using 

paper/manual processes. 

Using Aetna’s RTE via our website allows your office to 

save time, reduce phone calls and improve your bottom 

line. Check us out online today and experience first-hand 

one more way we’re putting technology to work for you. 


OfficeWise 

Referral Reminder for Specialists and 

Primary Care Physicians 

About Our Referral Policy 

To avoid delays in claim payments and to ensure cost-effective health care for your 

patients, please be sure to follow our referral process. 

■ 

■ 

■ 

■ 

For patients whose benefits plans require referrals, PCPs should complete and 

submit a referral, before the member sees the specialist. Be sure the referral 

includes the number of visits you are authorizing. 

We will no longer authorize claims from specialists to be paid at the member’s 

preferred/in-network benefit level if the PCP is listed as the referring physician 

on the specialist claim form, but the PCP has not issued a referral. 

We have reminded our members that 

without the proper referral from their 

PCP, they may face higher out-ofpocket 

costs. 

Electronic referrals are the fastest, 

easiest way to submit referrals. To 

access our online referral system, 

please go to www.aetna.com and 

register for our secure website. 

Pharmacy Precertification Unit Hours 

If your office still submits paper 

referrals, please note that they 

should no longer be sent to our 

Tyler, TX post office box. All paper 

referrals should be submitted to: 

Aetna 

P.O. Box 981288 

El Paso, TX 79998-1288 

The fax number for paper 

referrals remains unchanged: 

1-800-588-2386. 

Options to Reach Us 

The Secure Website 

Secure website for physicians, 

hospitals and health care 

professionals: 

■ Go to www.aetna.com 

■ 

■ 

Select “Doctors & Hospitals” 

Select “Physician Self-Service” 

and “Log In” 

Two Telephone Numbers 

Provider Service Centers 

and Aetna Voice Advantage, 

our voice response, self-service 

telephone system: 

■ 1-888-MD AETNA 

(1-888-632-3862) for calls 

related to indemnity and 

PPO-based benefits plans 

■ 1-800-624-0756 for calls 

related to HMO-based 

benefits plans 

OfficeLink Updates 

For queries or feedback regarding 

the OfficeLink Updates newsletter, 

contact us directly at 

OfficeLinkUpdates@aetna.com. 

The Pharmacy Precertification Unit’s regular hours are 

Monday – Friday 9 a.m. – 8 p.m. ET. 

The Precertification Unit will be closed on the following day: 

■ Independence Day (July 4) 


Spanish-Language Services Introduced — Free Blood Glucose Monitor Program 

Now Even More Accessible 

Aetna’s complimentary blood glucose monitor program is 

now even more accessible to your patients with our 

pharmacy benefits plans, thanks to the introduction of a 

full range of Spanish-language services and materials. 

As in the past, your patients with our pharmacy benefits plan 

who have diabetes or who you believe would benefit from 

monitoring blood glucose levels to avoid future development 

of the disease may receive a free blood glucose monitor. 

These members can simply call the Aetna Member Services 

toll-free number on their ID card and request a monitor. 

Now, however, Spanish-speaking customer service 

representatives are also available to speak to members, answer 

questions and assist them in obtaining a monitor. Newly 

diagnosed members will receive their requested blood 

glucose monitors via overnight service. 

Moms-to-Be With Gestational 

Diabetes Are Eligible For 

Blood Glucose Monitors 

Aetna Pharmacy Management 

also works closely with our 

Moms-to-Babies Maternity 

Management Program to 

identify and contact eligible 

members who are newly 

diagnosed with gestational 

diabetes about receiving the 

free monitors. 

Blood Glucose Monitor Vendors 

Offer Additional Bilingual Services 

In 2004, more than 20,000 blood glucose monitors 

were shipped to Aetna members. We are grateful for the 

support of these blood glucose monitor vendors and their 

bilingual services: 

■ 

■ 

Abbott Diabetes Care — Spanish training and 

educational materials are included with each 

complimentary Abbott blood glucose monitoring system 

starter kit offered through our program – Freestyle 

Flash, FreeStyle ® or Precision Xtra. Support in 

Spanish is available around the clock via the Customer 

Care toll-free service line at 1-888-522-5226. A Spanish 

interactive product demonstration is also available at 

www.Glucerna-Precision.com. 

LifeScan, a Johnson & Johnson company — Spanish 

training and educational materials are included with each 

complimentary LifeScan blood glucose monitoring meter 

starter kit offered through our program – OneTouch ® 

UltraSmart ® and OneTouch ® Ultra ® . LifeScan also 

provides Spanish-speaking users of OneTouch ® Blood 

Glucose Monitoring Systems a website 

www.OneTouchEnEspanol.com and a toll-free customer 

service line in Spanish (1-800-381-7226) that can be 

accessed 24 hours a day, seven days a week. 


Numbers to Know 

Provider Service Center 

HMO-based products including 

questions about claims, benefits and 

eligibility, policy and procedures, 

reimbursement 1-800-624-0756 

Utilization Management HMO 

including Precertification 

and Disease Management 

1-800-624-0756 

Provider Service Center 

Indemnity and PPO-based products 

including questions about claims, 

benefits and eligibility, policy and 

procedures, reimbursement 

1-888-632-3862 

Utilization Management PPO 

including Precertification 

and Disease Management 

1-888-632-3862 

Credentialing and Application 

Management, Status Questions, 

New Applications and Recredentialing 

1-800-353-1232 

Behavioral Health Services 

Refer to member’s ID card 

Member Health Education/ 

Women’s Health Programs 

Informed Health ® Line 

1-800-556-1555 

National Medical Excellence Program ® 

1-877-212-8811 

Breast Cancer Case Management 

Program 1-888-322-8742 

BRCA Genetic Testing Program 

(Genetic Testing for Breast and 

Ovarian Cancers) 1-877-794-8720 

Infertility Program 1-800-575-5999 

Healthy Outlook Disease 

Management Programs 

Refer to member’s ID card 

Moms-to-Babies Maternity 

Management Program 

1-800-272-3531 

Pharmacy 

Precertification/Medical 

Exception Request 1-800-414-2386 

Fax 1-800-408-2386 

Aetna Pharmacy Management 

Provider Helpline 1-800-238-6279 

Aetna Rx Home Delivery ® 

1-866-612-3862 

Specialty Pharmacy Network 

Aetna Specialty Pharmacy SM 

1-866-782-2779 (ASRX) 

Fax 1-866-329-2779 (FAX ASRX) 

Immunoglobulin Pharmacy 

Network 

American Outcomes Management 

of New York 1-866-869-7307 

Fax 1-817-361-9671 

IgG America 1-877-674-9700 

Fax 1-877-402-4042 

Priority Healthcare 1-877-417-5383 

Fax 1-877-417-5385 

Attentive IgG 1-888-883-8606 

Fax 1-800-881-0546 

Aetna Clearinghouse Options 

Availity 1-800-282-4548 

ENS 1-800-341-6141 

Gateway EDI 1-800-969-3666 

HDX 610-219-1600 

HealthFusion 215-393-4730 

NDCHealth 1-800-852-0707 

PayerPath 804-560-2400 

ProxyMed 1-800-586-6870 

The SSI Group 1-800-881-2739 

WebMD 1-888-215-4730 

For additional information on electronic 

connectivity with Aetna, please call us at 

1-888-247-1023. 

Web Addresses to Know 

Aetna 

www.aetna.com 

Secure website for physicians, 

hospitals and health care 

professionals: 

www.aetna.com/provider 

(website technical support – 

1-800-225-3375, 7 a.m. to 9 p.m., 

Monday – Friday, ET) 

DocFind ® www.aetna.com/docfind 

Formulary Guide 

www.aetna.com/formulary 

Clinical Policy Bulletins 

www.aetna.com/cpb/index.html 

Pharmacy Clinical Policy Bulletins 

www.aetna.com/formulary 

Women’s Health 

www.aetna.com/products/womenshealth 

Aetna InteliHealth ® 

www.intelihealth.com 

Aetna Specialty Pharmacy SM 

www.aetnaspecialtypharmacy.com 

American Outcomes Management of 

New York www.msadvances.com 

IgG America www.iggamerica.com 

Priority Healthcare 

www.priorityhealthcare.com 

Attentive IgG www.attentiveigg.com 

Aetna Clearinghouse Options 

Availity 

ENS 

Gateway EDI 

HDX 

www.availity.com 

www.enshealth.com 

www.gatewayedi.com 

www.hdx.com 

HealthFusion www.healthfusion.com 

NDCHealth 

PayerPath 

ProxyMed 

www.ndchealth.com 

www.payerpath.com 

www.proxymed.com 

The SSI Group www.thessigroup.com 

WebMD 

www.webmdenvoy.com 

For additional information on electronic 

connectivity with Aetna, please call us at 

1-888-247-1023. 


Policy & Practice Updates 

Payment Policy for Doppler Color Flow Velocity 

Mapping CPT 93325 

Doppler echocardiography color flow 

velocity mapping (CPT 93325) 

displays the instantaneous velocity 

and direction of blood flow, allowing 

for detailed physiological and 

functional information to be obtained 

non-invasively. Although the technical 

capacity to perform this study may be 

readily available, it may not be useful 

in many clinical circumstances. 

Effective September 1, 2005, 

Aetna will limit coverage for 

doppler echocardiography color flow 

velocity mapping in adults to those 

indications for which this diagnostic 

study is considered useful. The 

ACC/AHA/ASE 2003 Guideline 

Update for the Clinical Application of 

Echocardiography 1 is intended to assist 

physicians in clinical decision making 

by describing a range of generally 

acceptable approaches for the 

diagnosis, management, or prevention 

of specific diseases or conditions. 

Clinical Situations for Color 

Doppler 

Color Doppler is noted to be useful 

only in the following clinical 

situations: 

■ 

■ 

■ 

■ 

■ 

Evaluation of septal defects 

Evaluation of the severity of valve 

stenosis or regurgitation 

Evaluation of site of left-to-right or 

right-to-left shunts 

Assessment of diseases of the aorta 

Evaluation of prosthetic valves 

Please note that Aetna will not change 

coverage policies for M mode, 2D and 

Spectral Doppler studies or for 

transesophageal echocardiography. 

1 American College of Cardiology/ 

American Heart Association/American 

Society of Echocardiography. 2003 

Guideline: Clinical Application of 

Echocardiogram (Cheitlin, et al. 2003). 

Policy Update for 

Physicians Fulfilling 

Military Service 

To support our physicians engaged 

in military service, we allow 

participating physicians and other 

health care professionals to remain in 

the Aetna network while they are 

fulfilling their military obligations. 

Recredentialing is suspended for 

providers on military leave, and their 

information is temporarily 

suppressed so they won’t appear in 

DocFind ® , our online referral 

directory, or in printed directories. 

We thank our participating 

physicians for their military service 

and wish them a safe return. 

Military Service — 

Simply Inform Us When 

You Leave and Return 

Notify Aetna of your military 

obligation using: 

Aetna Credentialing Customer 

Service 1-800-353-1232 


Clinical, Payment and Coding Policy Changes 

As part of Aetna’s ongoing policy review process, we regularly adjust our clinical, 

payment and coding policy positions and urge physicians to consult our website 

on a regular basis. We are firmly committed to establishing and maintaining 

clinical policies that are based on solid, peer-reviewed studies, scientific data and 

best-practice guidelines within the medical community. In developing our 

payment and coding policies, we also collaborate with external professional 

organizations, medical societies and associations. We also receive feedback from 

individual practicing physicians, such as those on the independent Physician 

Advisory Board, which provides advice to us on issues of importance to physicians. 

Recently, we made several positive coding and policy changes that we want to 

share with you. The chart below outlines the changes. 

Find all Clinical, Payment 

and Coding Policy Changes 

on the Website 

Clinical policy changes are 

documented in Clinical Policy 

Bulletins (CPBs). To access CPBs, 

go to “Clinical Resources” on the 

secure website and select “Clinical 

Policy Bulletins.” 

To access payment and coding 

changes on the secure website, 

go to “Claims,” and then select 

“Policy Information” and choose 

“Payment and Coding Policies.” 

CODE(S) 

IMPACTED 

76082, 

76083 

POLICY 

Digital 

Mammography 

REASON FOR CHANGE 

We consider computer-aided detection (CAD) a 

medically necessary adjunct to mammography. 

Digital mammography is an acceptable alternative 

to screen film mammography. Policy changes 

regarding mammography and CAD can be found 

in Clinical Policy Bulletin #584. 

Based upon additional information provided by 

the American Urological Association and 

discussions with the Physician Advisory Board, we 

will allow separate reimbursement of codes. 

Input from the American College of Radiology 

and the American Society for Therapeutic 

Radiology and Oncology, as well as discussions 

with the Physician Advisory Board, created a 

change to allow reimbursement of code 77336. 

Based on additional information from the 

American College of Cardiology and the American 

Society of Nuclear Cardiology, as well as discussions 

with the Physician Advisory Board, we will allow 

separate reimbursement of codes. 

We worked with the American Society of Retina 

Specialists to make these changes based on new 

information. Changes are found in Clinical Policy 

Bulletin #344. 

SUMMARY 

Allow payment of code 

DATE OF 

CHANGE 

04/01/2005 

76872 / 

76942 

Rectal 

Ultrasound 

& Biopsy 

Allow separate payment 

of codes 


77336 

Radiation 

Physics 

Consult 



78478 / 

78480 

Ejection 

Fraction 

(add-ons) 

Allow separate payment 

of codes 


92135 

Ophthalmic 

Imaging 

Retinal 


for glaucoma, retinal 

diseases and optic nerve 

disorders but not routine 

screening of the general 

population 



Striving for 

Quality Excellence 

Medical Record Policy 

To assist you in delivering the best possible care to your patients, we 

have established five important criteria and documentation standards for 

all participating practitioners. For your reference, these standards are 

highlighted below. 

1. CONFIDENTIALITY 

Participating practitioners must treat the following information as 

confidential in accordance with their Aetna contract and applicable 

laws. Information that: 

■ Identifies a member 

■ Specifies the relationship of the member with Aetna 

■ Addresses physical or mental health status or condition 

■ Identifies the provisions of health care and payment details 

Participating practitioners must maintain administrative, technical and 

physical safeguards to protect the privacy of members’ protected health 

information (PHI). 

2. MAINTENANCE AND AVAILABILITY OF MEDICAL RECORDS 

■ Contractually, practitioners agree to maintain medical records in a 

current, detailed, organized and comprehensive manner in accordance 

with customary medical practice, applicable laws and accreditation 

standards. This requirement survives the termination of the contract, 

regardless of the cause for termination. 

■ 

Aetna shall have access to medical records, including confidential 

information, for the purpose of claims payment, assessing quality 

of care, medical evaluations and audits, and utilization management 

functions. 

3. MEDICAL RECORD DOCUMENTATION STANDARDS 

Our medical record documentation standards provide a guideline for 

fundamental elements of organization, documentation of diagnostic 

procedures and treatment, communication and storage of medical records. 

For the most up-to-date and complete guideline, refer to the Health Care 

Professional Toolkit on the secure website. 

4. ASSESSMENT 

Each year, Aetna audits a selected sample of PCP offices to assess 

compliance with medical record documentation standards. 

5. PERFORMANCE GOALS 

In the North Central Region, 100 percent of audited PCP practices will 

score 85% or greater on the documentation review. 

Our medical record criteria and 

documentation standards are 

available in the Health Care 

Professional Toolkit, on the secure 

website. Visit www.aetna.com. 

Select “Doctors & Hospitals,” 

select “Self-Service” and log in. 

Then click on “Doing Business 

with Aetna” and select “Health 

Care Professional Toolkit.” 


Specialties in Practice 

Women’s Health 

Obstetric Ultrasound Codes: 

When to Use CPT Code 76805 

76811, 76812 and 76805 

Obstetric ultrasound CPT code 76805 

For plans where obstetric ultrasounds is intended for evaluating the number 

are reimbursed on a fee-for-service of fetuses, or amniotic/chorionic sacs; 

basis, Aetna will reimburse CPT codes surveying intercranial, spinal, and 

76811, 76812 and 76805 only if they abdominal anatomy; evaluating a 

are submitted with a diagnostic code four-chamber heart view; assessing the 

reflecting the presence of a condition umbilical cord insertion site; assessing 

for which this advanced imaging study the amniotic fluid volume; and 

is indicated. 

evaluating maternal adnexa when 

visible when appropriate. 

When to Use CPT Codes 76811 

2 

and 76812 

For more information about this 

These obstetric ultrasound codes are policy, please refer to our Clinical 

appropriate only when evaluating Policy Bulletin #199 “Ultrasound for 

known or suspected anatomic or Pregnancy.” To access all of our 

genetic abnormalities in a fetus. They Clinical Policy Bulletins, go to 

are appropriate for pregnant women www.aetna.com, put your cursor over 

with a history of a previous anomalous “Doctors & Hospitals” and then click 

fetus or after an abnormal scan in the on “Clinical Policy Bulletins.” 

current pregnancy suggests an 

anatomic abnormality. 1,2 1 

These codes 

Copel J. Ultrasound Med. 2003 Jan; 

22 (1):1-3. 

are not intended to be routine scans 

2 SMFM Coding Committee. White Paper 

performed for all pregnancies. 

on Ultrasound Code 76811. Available 

at www.smfm.org. Accessed March, 

2004. 

This practice is consistent with the 

recommendations by the Society for 

Maternal Fetal Medicine (SMFM) and 

the American Institute of Ultrasound 

in Medicine (AIUM). According to 

AIUM, CPT 76811 requires 

additional technological sophistication 

and imaging expertise compared to all Fast Fact 

other obstetric ultrasounds. Its 

May is Mental 

performance “is expected to be rare 

Health Month. 

outside of referral practices with special 

expertise in the identification of, and 

counseling about, fetal anomalies.” 1 

Behavioral Health 

Behavioral Health Benefits 

We want our members and 

providers to be knowledgeable 

about available behavioral health 

benefits and services. We encourage 

you to discuss behavioral healthrelated 

issues with your patients to 

assist them in pursuit of wellness. 

Behavioral health benefits may 

differ based on the member’s 

benefit plan but usually include 

mental health and substance abuse 

coverage for both inpatient and 

outpatient levels of care. In 

addition, you are encouraged to 

consider referring patients who may 

benefit from Aetna’s behavioral 

health case and disease management 

programs, when such services are 

purchased by a plan sponsor. 

Other programs, such as Employee 

Assistance Program (EAP), when 

purchased by a plan sponsor, can 

help your patients with stress, 

family and other issues, including 

work life issues. 

(continued on page 12) 


Behavioral Health 

(continued from page 11) 

Answers Are Just a Phone Call Away 

Your Aetna patients may have behavioral health benefits 

from Aetna or another behavioral health provider. Either 

way, for questions or to pre-authorize behavioral health 

benefits, simply refer to the back of the member’s ID card. 

Good Mental Health Improves Physical Health 

Improving mental health can significantly improve physical 

health. In addition, coping with a health crisis or poor 

physical health can be emotionally challenging for your 

patients. Likewise, poor mental health can lead to adverse 

physical symptoms. Coordination of care between medical 

and behavioral health providers leads to healthier patients. 

Caring for chronically or seriously ill patients can have 

significant impact on the caretakers, too. Various studies 

show that 24 to 60 percent of caregivers show signs of 

nonclinical depression. Caregivers may also benefit from 

behavioral health services. More information on behavioral 

health can be found on our website at 

www.aetnabehavioralhealth.com. 

Resources for Mental Health and Well-being 

The Reawakening Center SM is part of our personalized online health and wellness program, which is available to the general 

public at www.reawake.com. The Center presents information about depression in a creative and supportive way with 

interactive tools, self-tests and an information library. It helps people learn more about themselves, discover ways of dealing 

with their feelings and emotions, and understand when they might benefit by seeking professional help. 

We have included additional resources that can assist you when providing guidance and treatment to your patients suffering 

with depression. Please feel free to photocopy this chart and share it with your patients. 

TOOL 

Aetna Navigator 

For Aetna members only 

The Informed Health ® Line 

For Aetna members only 

Aetna InteliHealth ® 

Reawakening Center 

National Institute of 

Mental Health (NIMH) 

National Mental Health 

Association (NMHA) 

National Alliance for 

the Mentally Ill (NAMI) 

The MacArthur Foundation 

HOW TO ACCESS 

www.aetna.com 

1-800-556-1555 

www.intelihealth.com 

www.reawake.com 

www.nimh.nih.gov or 

1-800-421-4211 

www.nmha.org or 

1-800-969-NMHA (6642) 

www.nami.org or 

1-800-950-NAMI (6264) 

www.depression-primarycare.org 

INFORMATION 

Our member and consumer website provides access to 

Healthwise ® Knowledgebase and to health information. 

A 24-hour toll-free, direct phone link to a team of 

registered nurses experienced in providing information 

on a variety of health topics. 

Aetna’s online health source consumers can trust; quality 

health information developed by Aetna Intelihealth and 

reviewed by Harvard Medical School or the Columbia 

University School of Dental and Oral Surgery; features 

weekly e-mail newsletters on health topics. 

A depression information site that provides participants 

with creative, supportive and non-threatening tools to 

uncover ways to deal with feelings and emotions and 

develop insight into when to seek professional help. 

Provides additional information and resources for 

depression. 


depression. 


depression. 


depression. 

Additional resources can be found online on our secure website. Visit www.aetna.com and select 

“Physician Self-Service” under “Doctors and Hospitals.” This link provides access to a continuing 

medical education program on depression, depression screening tools, patient education 

information, Depression Clinical Practice Guidelines, and Clinical Policy Bulletins. 


Plan Facts & Features 

Aetna Offers a Solution to the Uninsured Part-Time and Hourly Workers 

According to the U.S. Census Bureau, there are 45 million 

uninsured Americans, with the numbers continuing to grow. 

Most of these uninsured workers are actually holding down 

multiple part-time jobs. Up to 40 percent of them 

commonly do not receive necessary medical care. In 

addition, they receive fewer preventive services or seek less 

care for chronic conditions than their insured counterparts. 1 

Our limited major medical benefits plans for part-time and 

hourly workers — Aetna Affordable Health Choices SM — 

will help lower the number of uninsured Americans. 

You Will Recognize These Patients by Their 

New ID Cards 

Starting May 1 st , Aetna Affordable Health Choices 

indemnity and PPO members will receive ID cards with the 

Aetna logo and “Aetna Affordable Health Choices” on the 

front, along with the unique member reference number 

“SRC5555.” ID cards for members in the PPO plan will also 

include the word “PPO.” See the sample Aetna Affordable 

Health Choice ID cards: 

Aetna Simplifies Plan Administration 

As part of our commitment to bridge the uninsured 

gap, in January 2005 we acquired Strategic Resource 

Company (SRC). SRC is a benefits company that 

administers group benefits for part-time and hourly 

workers. As a subsidiary of Aetna, effective May 1, 2005, 

they will administer benefits under a portfolio of products 

known as Aetna Affordable Health Choices. As a result, 

you will see positive enhancements when providing care 

to Aetna Affordable Health Choices patients, including: 

■ 

■ 

■ 

A new toll-free number to call SRC customer 

service – 1-888-772-9682. 

A customized version of DocFind ®, giving you an 

online listing of PPO participating providers instead 

of having to call customer service each time. 

Previously, SRC could accept only paper claims. 

Effective May 1, your offices will be able to submit 

claims electronically. Please use the payer ID located 

on the Member ID card to submit claims through 

Aetna’s established EDI channels. In the future, you 

will also be able to utilize Aetna’s EDI channels for: 

—Verification of claim status 

—General benefits and eligibility information 

—Electronic remittance advice 

Most SRC existing members will be transitioned to the 

Aetna Affordable Health Choices plans upon their plan 

sponsor’s plan renewal. During this transition period 

that will run through mid-2006, you may see existing 

SRC ID cards. 

(continued on page 14) 

1 Smart Business – Part-Time Health Plans, March 1, 2005. 


Aetna Offers a Solution to Uninsured Part-Time and Hourly Workers 

(continued from page 13) 

There Will be Administrative Differences With These 

Benefits Plans 

■ All Aetna Affordable Health Choices related calls from 

providers and members will be handled by the SRC 

customer service staff via a toll-free customer service 

number (1-888-772-9682) listed on the ID card. 

■ We strongly encourage that you call every time to verify 

eligibility for Aetna Affordable Health Choices patients. 

At that time please provide the member reference 

number “SRC5555” to assist in addressing your call 

promptly. After you call, customer service will send you a 

benefits and eligibility information fax. The fax is not a 

guarantee of payment. 

■ When submitting claims electronically please use: 

—Payer ID 57604 

—Patient’s Social Security number for the member ID 

■ 

All claims not submitted electronically should include: 

—Payer ID 57604 

—Patient’s Social Security number for the member ID 

Submit paper claims to: 

SRC, an Aetna Company 

P.O. Box 23759 

Columbia, SC 29224-3759 

For More Information on Aetna 

Affordable Health Choices 

If you have questions regarding these new benefits plans, 

please contact SRC customer services at the number listed 

above or go to the link on our secure website under Doing 

Business With Aetna. 


In Your Area 

ILLINOIS, COLORADO, OHIO, INDIANA, 

MISSOURI, KENTUCKY AND KANSAS 

Phone, Fax and Web Contacts for Radiology 

Precertification 

National Imaging Associates (NIA) 

administers Aetna’s radiology 

utilization management program in 

your area. NIA has a dedicated toll-free 

number for Aetna members requiring 

high-tech radiology precertification. 

This program affects most Aetna 

HMO, QPOS ® , Aetna Open 

Access HMO, Aetna Choice 

POS and USAccess ® members in 

your market. 

Precertification is Required for 

Certain Procedures 

The program includes a 

precertification requirement for certain 

outpatient, elective, high-technological 

imaging procedures including: 

■ CTs 

■ MRI/MRAs 

■ PET scans 

■ Nuclear Cardiac Imaging Studies 

Radiology procedures performed 

during an inpatient stay or in an 

emergency room do not require 

precertification. 

Precertification List Now 

on the Website 

A complete list of the outpatient nonemergency, 

high-tech radiology 

procedures that require precertification 

is available on the secure website: 

1. Go to the Aetna 

Communications section under 

“Doing Business with Aetna.” 

2. Select “Mailings,” “2005” 

and your state. 

3. Find “High-Tech Radiology 

Precertification List.” 

As a reminder, when calling NIA 

for precertification, please have the 

following information available: 

■ Aetna member ID number 

■ Patient date of birth 

■ Current diagnosis, treatment 

history and plan 

■ Patient chart 

■ Medications 

■ Previous imaging study results 

For additional information, please 

contact your Aetna provider relations 

representative. 

Pri-Med Updates 

Milwaukee 

June 3-4, 2005 

Hyatt Regency Milwaukee 

For more information, visit 

www.pri-med.com 

Columbus 


Renaissance Columbus 



Pri-Med Conference 

& Exhibition 


Donald E. Stephens Convention Center 

Rosemont, IL 



Toll-Free Numbers for NIA 

For Aetna members that 

require precertification 

CALL 1-866-326-6304 

To submit Aetna 

precertification requests 

FAX 1-800-784-6864 


CPE RS51 

151 Farmington Ave. 

Hartford, CT 06156 

PRSRT STD 

U.S. POSTAGE 

PAID 

PERMIT NO. 12 

ENFIELD, CT 

Please route this publication to: 

❑ Office Manager 

❑ Business Staff 

❑ Front Desk Staff 

❑ Medical Records/Medical Assistants 

❑ Primary Care Physicians 

❑ Specialists 

❑ Physician Assistants/Clinical 

Nurse Specialists 

❑ Nurses 

❑ Referral and Precertification Stafftaff 

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The 

Aetna companies that offer, underwrite or administer benefit coverage include Aetna Health Inc., Aetna Health of Illinois Inc., Aetna 

Life Insurance Company and Corporate Health Insurance Company. 

2005 Survey on its Way: We Want to Hear From You 

Summer is almost here and that means the 2005 Primary Care 

Physician and Practice Manager Survey is on its way! A sample 

of Aetna contracted physicians and practice managers will 

receive the 2005 Primary Care Physician and Practice Manager 

Survey. If your office is selected to receive the survey, we hope 

you will take 5 or 10 minutes to complete it so your voice will 

be heard. 

What We’re Doing to Improve Our 

Relationship With You 

■ The nine-member Physician Advisory Board met twice in 

2004 to discuss issues of importance to physicians and 

provide guidance on health care issues of national scope. To 

review the board’s meeting summaries or to propose topics 

for future meetings, go to www.aetna.com, click on 

“Doctors & Hospitals,” and then click on “Physician 

Advisory Board.” 

■ 

■ 

■ 

■ 

We’ve removed from our 2005 Precertification List some of 

the items that previously required precertification. 

Our Provider Service Centers have customer service 

professionals to handle all your provider-related calls and 

questions: 1-800-624-0756 for calls related to HMO-based 

plans, and 1-888-MD-AETNA (632-3862) for calls related 

to indemnity and PPO-based plans. 

Our enhanced Aetna Voice Advantage ® (AVA) system 

allows you to check on claim status and benefits coverage 

for multiple patients participating in different plans. 

Our secure website at www.aetna.com allows you to verify 

member eligibility, check on the status of claims and submit 

new claims, obtain precertifications within seconds, submit 

referrals, update your office information, search our online 

physician referral directory DocFind ® , and much more. 

The information and/or programs described in this newsletter may not necessarily apply to all services in this region. Please 

contact your Aetna network representative to find out what is available in your local network. This newsletter is provided 

solely for your information and is not intended as legal advice. If you have any questions concerning the application or 

interpretation of any law mentioned in this newsletter, please contact your attorney. 

23.22.807.1-NC (5/05) 

©2005 Aetna Inc.

May/June 2005 - Center Care Health Benefits Programs

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