Update on Claims Processing for the Aetna/NIA Prior Authorization Program

Please note the following update relative to Aetna's new Prior Authorization Program which went into effect 9/1/18.

The NYSCA is aware that many of you still have questions regarding this program, have not yet attended a Webinar, are unsure of reimbursement, or have not signed a contract.  For those of you who have not yet attended a Webinar, we have asked Aetna to make additional Webinars available (perhaps even one which can be recorded and made available so docs and/or their staff can view at times which may be more convenient for you).

We also understand there is some confusion as to which plans require prior authorization, as different information has been conveyed to different members. Some of you were advised by Aetna representative to continue to send claims to Optum (which would not be the case for services rendered on or after 9/1/18). Please note that NYSCA has been in contact with Aetna to clarify this information, and will be meeting with them in the near future. In the interim we recommend calling Aetna for patients who enter your office on or after 9/1/18 to verify benefits and claims address and to also inquire as to whether or not prior authorization is required. As always document the time, date and representative with whom you or your staff spoke with.

The information below is relative to claims processing after you receive an authorization. Please note that Aetna reached out to NYSCA directly once they learned of this issue. They will identify inappropriately denied claims proactively - you do not need to rebill Aetna. You do not need hold your claims.

From Aetna:
What you need to know:

If you received an authorization from NIA and the claim denies for no authorization, Aetna will be reprocessing your claim.

    • Aetna will generate a report of all claims billed with a date of service between 09/01/2018 and 09/14/2018
    • Any claim denied for no authorization will be reviewed to determine if an authorization is on file.
    • If an authorization is on file, Aetna will reprocess the denied claims.

Our claims and call staff are aware of this situation and will properly address questions from impacted providers.

Once we confirm all of the details, we will follow up with your association with more information, including the expected completion date. We appreciate your patience and understanding.

Again, NYSCA appreciates when carriers reach out to us proactively, and those who address our member's issues quickly and responsibly. We are aware that many of you have not received adequate or required notice of this important program change. We will continue to work with you and Aetna to assist with this transition.


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