(HMO) (PPO) Provider Directory Central New Jersey - Aetna Medicare

Section 1 – Introduction
This directory provides a list of Aetna Medicare (HMO)
(PPO) network providers. To get detailed information
about your health care coverage, please see your
Evidence of Coverage.
If you are enrolled in a standard Aetna Medicare
Health Maintenance Organization (HMO) plan,
you will have to choose one of our network providers
who are listed in this directory to be your Primary Care
{Physician/Provider} (PCP). The term “PCP” will be
used throughout 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. You must use network providers except for
urgent care or out-of-area urgent care or renal dialysis.
Except for those benefits described in your plan
documents as direct-access benefits, or in an
emergency, you will need to obtain a referral from
your PCP before seeking covered non-emergency
specialty or hospital care. You must use plan providers
except in emergency or urgent care situations or for
out-of-area renal dialysis. If you obtain routine care
from out-of-network providers neither Medicare nor
Aetna Medicare will be responsible for the costs.
If you are enrolled in an Aetna Medicare (HMO)
Open Access plan, you are not required to choose
a primary care physician (PCP) and are free to visit
network providers without a referral to receive covered
services. You must use network providers except for
an emergency, urgent care, out-of-area urgent care,
or renal dialysis. If you obtain routine care from
out-of-network providers neither Medicare nor Aetna
Medicare will be responsible for the costs.
If you are enrolled in an Aetna Medicare
Preferred Provider Organization (PPO) plan, you
have the flexibility to choose either network providers
to receive covered services at lower out-of-pocket
costs, or out-of-network providers at a higher cost
sharing level. With the exception of emergencies,
urgent care or out-of-network renal dialysis, it may
cost PPO members more to get care from out-ofnetwork
providers. You can use any Aetna Medicare
PPO network PCP and pay the plan’s lower primary
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doctor visit copay. Although you are not required to
select a PCP, you are encouraged 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 and are eligible to receive Medicare
payment.
The “network providers” listed in this directory have
agreed to provide you with your health care, vision,
hearing and dental coverage. You may go to any of
our network providers listed in this directory; however,
some services may require a referral. If you have been
going to one network provider, you are not required
to continue going to that same provider. In some
cases, you may get covered services from non-network
providers.
In cases where non-contracting providers submit a bill
directly to you, you should not pay the bill, but submit
it to Aetna Medicare for processing and determination
of your financial liability, if any.
Certain health care services, such as hospitalization or
outpatient surgery, require precertification with Aetna.
This means the service must be approved by Aetna
before it will be covered under the plan. Check your
Evidence of Coverage for a complete list of services
that require this approval. When you are to obtain
services requiring precertification from a participating
provider, the provider is responsible to precertify those
services prior to treatment. If your plan includes an
out-of-network benefit and you decide to receive
covered services from an out-of-network provider it is
your responsibility to contact Aetna to precertify those
services.
If you need emergency care, you are 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 (ex. 911) or go to
the nearest emergency facility. If a delay would not
be detrimental to your health, call your PCP. Notify
your PCP as soon as possible after receiving
treatment.
■ If you are admitted to an inpatient facility, you or a
family member or friend on your behalf should
notify your PCP or Aetna as soon as possible.
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