Further Updates on Aetna/NIA Prior Authorization Program

Members of the NYSCA insurance committee met with Aetna and NIA to discuss the implementation of the new Pre-Authorization Program which went into effect on 09/01/18.  We understand that many of you were not notified until late July / early August and could not attend NIA's webinar on August 7, 9 or 16.  There has been some confusion regarding different aspects of the program, resulting in our reaching out to Aetna to discuss your concerns.

What we know:


If you are currently contracted with Optum to render care to Aetna insureds, those contracts are scheduled to remain in effect until 12/31/18.  The Aetna portion of those contracts will end.  In the interim, you must contract directly with Aetna to continue to provide services as a network provider.  

If you are not currently contracted with Aetna or were in the process of having Aetna added to your Optum contract, you must sign a new agreement directly with Aetna at your earliest convenience.  Aetna must receive your signed agreement no later than 10/15/18.  This will allow Aetna time to communicate with Optum as to which doctors either resigned or simply did not respond to contracting.  

Note that health plans have a responsibility to notify patients under your care when there is a change in your participation status.  Typical notification incorporates either the names of contracted / participating providers located near the patient or instructions on how they may locate a participating provider in their area. In addition, if you decide not to continue as a participating provider, be aware that Chapter 60 of New York's Laws of 2014 amended NYS Public Health Law adding § 24 - "Disclosure," which requires Title VIII health professionals, including chiropractors, to "disclose to patients or prospective patients in writing or through an internet website, the health care plans in which the health care professional, group practice, diagnostic and treatment center or health center, is a participating provider."

As always, federal antitrust laws do not allow the NYSCA to advise you on whether or not to contract with any group.  Always weigh the risk/benefits as you consider your patient population, program requirements (e.g., authorization process and claim submission), reimbursement, and other applicable items when rendering your determination. We have inquired about how providers considering this decision can get access to the fee schedule and are awaiting instruction.

Take home message: Your current Optum contract remains in effect until 12/31/18. If you wish to continue to participate with Aetna, you must sign an agreement directly with Aetna no later than 10/15/18 to avoid risking your participation status. 

Utilization Management / Pre-authorization

Aetna has contracted with Magellan / NIA to render medical necessity determinations for services rendered after 8/31/18 to the commercial fully-insured and Medicare populations.  This is a big change and reminiscent of the authorizations provided by CPT code or groupings in the late 80's/early 90's.  To best understand their process you must attend an NIA Webinar (see Webinar section below). 

Submission time-frame: 5 days.  We have discussed the 5 day submission requirement (presumption is 5 business days but we will seek confirmation) as being the most restrictive in New York (many carriers and TPAs allow up to 6 months / retrospective review which is not available with this plan).  

Since the Optum contract remains in effect, we stressed that the submission rules associated with the Optum program should remain in effect until 12/31/18 unless there are new contracts in place which require providers to submit their documentation within 5 days.  Aetna is looking into that issue.  We are hopeful that a more appropriate submission time-frame will be implemented, especially when you have patients currently under care.  At least that will give providers a more reasonable time-frame to submit their documentation.

Despite your ACN/Optum contract, there is no authorization waiver for Tier one providers.

Method of submission:

  1. You may call for authorization (note in New York, a non-clinical staff member working for an insurance company or their third party administrator such as NIA can only say 'yes' to a request).  If you call and agree with the authorization provided, no further documentation is required.  If you disagree you must submit clinical documentation.
  2. Submit documentation via the RadMD.com web portal.  Note that in this instance you are providing initial demographics and liability information on line, however you must upload your Initial examination, progress notes, and treatment plan. 
  3. You may complete a fax cover and fax your initial evaluation, progress notes and treatment plan to NIA.

There is no form or template to assist you or NIA in submitting your clinical documentation.  Properly completed evaluation and treatment notes are necessary.  We did inquire as to patients that were under care prior to 09/01/18.  The initial evaluation, progress notes, re-evaluation and treatment plan would be necessary; however, if there has been a significant gap in care and the prior information is not applicable to their current condition, a more contemporaneous evaluation, progress notes and treatment plan should suffice.

There does not appear to be any retrospective review available.

Applicability: Based upon your confusion on which groups this may apply to, we did obtain the following information from Aetna: This only applies to the commercial fully-insured and Aetna's Medicare plans.  Aetna noted that most of the patients in this region are self-funded and hence authorization through NIA is not required.  

Aetna did also suggest logging in to RadMD, enter the member's ID.  You will receive an immediate automated response if authorization is not required.  Aetna is sending weekly lists of applicable insureds to NIA, so the accuracy of this information is expected to be '99.5%'.  

We did inquire as to whether these patients can be easily identified by the Insured ID Card or ID number.  Aetna is updating the FAQ relative to this program including more details on the impacted patient population and how to best identify applicable patients. 

Take Home Message: Check your current Aetna patients and all new Aetna patients to see if pre-authorization is required in a timely manner to ensure you do not miss the 5 day pre-authorization requirements.


The current fee schedule which applies to your current Aetna insureds will remain in place until 12/31/18.  Claims are processed by Aetna in accordance with NIA's authorization.  There has been a slight delay in loading the Optum fee schedule for those applicable patients.  If your claims are not processed in accordance with your Optum schedule, Aetna will proactively identify those claims and have them reprocessed.  You do not have to resubmit those claims (the NYSCA recommends tracking any such claims at your office to ensure they are reprocessed in a timely manner).  A new fee schedule is being developed by Aetna for services rendered on/after 01/01/19.  Aetna understands you need that information as one of the key factors in making your determination to participate in this new program. 

Take home message: Current reimbursement levels remains in effect until 12/31/18; Claims are submitted to Aetna; Ensure your authorization is obtained prior to billing; A new fee schedule is forthcoming from Aetna for services rendered on/after 01/01/19.

Webinars and Future Educational Presentations

NYSCA recognizes that Wednesday's 8am webinar was scheduled during Yom Kippur.  Although we have not been involved in the scheduling of any of their webinars, we have requested that additional times and dates be made available.  NIA has found that 8am and 12pm work best, but is looking for our input.  Please call / fax NYSCA and advise with days and time-frames work best for  you.  

We have also requested (both in writing and via call) that the webinar information be made available online so providers can review this information at a time that is convenient for the doctor and their staff.  Aetna appreciated the concept and will have NIA do so in the near future.  

Take home message: Aetna and/or NIA will be scheduling more webinars and is looking to post a self-paced webinar as well.  We will post this information as soon as we hear back from Aetna or NIA.  If you are informed of an upcoming Aetna / NIA webinar please let us know so that we may inform others.


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