Sample Referral Letter from Physical Therapist to Doctor

Document Sample
Sample Referral Letter from Physical Therapist to Doctor Powered By Docstoc
					                                                                                             Section III.



               Local Network Information
Your Key Regional Contacts

                    Department                                  Contact Information
  Aetna Switchboard                                  1-800-US-Aetna or 1-800-872-3862
  You may contact this number for claim office
  contact information, if the member’s ID card is
  not available.
  Provider Services
                    HMO                              1-800-624-0756
                    Traditional                      See Member ID Card
  Information on Specialty Networks                  1-800-624-0756
  (e.g., Chiropractic, Laboratory, Radiology, etc)
  Behavioral Health                                  Refer to Local Market Section
  Precertification of Admissions (24 hours/7         1-800-245-1206 – HMO
  days a week)                                       1-800-223-6857 – MC/EPO
                                                     See Member ID Card – PPO/TC
                                                     Please listen for appropriate options
  Home Care/Ambulance Transport                      1-800-245-1206
                                                     Please listen for appropriate options
  Nonparticipating Requests                          1-800-245-1206
                                                     Please listen for appropriate options
  Case Management/Utilization                        1-800-245-1206
  Management/Injectable Requests                     Please listen for appropriate options
  (also: Skilled Nursing Placement and Inpatient
  Rehab)
  Radiology Imaging Programs                             See Phone Numbers Below
                                                         Please Refer to Market Specific Section for
                                                          Additional Information
          New Jersey                                 Care Core
                                                         Pre-Cert & Customer Service
                                                                    1-888-647-5940
          Greater Metro New York                     Care Core
                                                         Pre-Cert & Customer Service
                                                                    1-888-622-7329
          New England                                MedSolutions
           (Includes CT, MA & ME)                        Precert & Customer Service
                                                                    1-888-693-3211
  Physician Credentialing and Application            1-800-353-1232
  Status




                                                 III-1            Local Network Information - Northeast
Northeast Region Behavioral Health Vendor Information
  Aetna members may seek treatment from a participating behavioral health professional without
  obtaining a referral from their primary care physician (PCP). However, the pre-certification
  through Aetna’s behavioral health contractor, is required. Members must contact the behavioral
  health vendor in order to:
  • Find a participating behavioral health provider in their area
  • Obtain pre-certification for mental health and substance abuse services.

  Precertification
  Inpatient and Outpatient precertifications are required and can be obtained by the member, the
  PCP or a behavioral health professional, on the member’s behalf.

                            HMO Behavioral Health Contact Information
                State                     Service Vendor                    Phone Number
      Connecticut                Behavioral Health Connecticut          1-877-593-5061
      Massachusetts              Magellan                               1-800-424-6108
      Maine                      Magellan                               1-800-538-3859
      New Hampshire              Magellan                               1-800-424-5726
      New Jersey                 Magellan                               1-800-424-5964
      New York(except Bronx)     Magellan                               1-800-755-2422
      New York (Bronx)           University Behavioral Associates       1-800-401-4822
      Rhode Island               Magellan                               1-800-424-6130
                                    Traditional Behavioral Health
                  Please contact the phone number located on the member’s ID Card.

  Members should follow the guidelines below when seeking mental health and substance abuse
  services:

  •   Contact the vendor first so they can pre-certify and arrange all routine, urgent and emergency
      behavioral health and substance abuse services.

      In an emergency, the member should seek care immediately. If a member needs to go to an
      emergency room for a mental health or substance abuse crisis, please contact the vendor for
      assistance in managing the admission and any referrals for additional behavioral health
      services that may be needed. Although a PCP referral is not needed for these types of
      emergency room services, the members PCP should be notified.

  Please Note: Because a PCP referral is no longer necessary for mental health and
  substance abuse services, it is very important that the member contact MBH to obtain
  necessary authorizations and referrals for these types of services.

  Also Note: Some employers may have selected a Behavioral Health Contractor other than
  those above to manage their Behavioral Health benefits. If you have any questions with
  regard to the Behavioral Health Contractor for a member, contact Aetna provider services
  at 1-800-624-0756 or the number listed on your patient’s member ID card for Traditional
  products.




                                                 III-2           Local Network Information - Northeast
Capitated Programs

  Capitated programs apply to Aetna HMO, QPOS, US Access, Open Access HMO, Aetna
  Choice POS and Golden Medicare plans only, when available in a local market.

  Aetna has established capitation programs for certain outpatient specialties. Each capitated
  provider is contracted to provide a full range of services and can be identified by PCPs as the
  vendor of choice for Aetna members by contacting our physician service area at 1-800-624-0756.
  The capitated programs may include the following services:


                                 Program Descriptions
  Laboratory                  When a PCP or a specialist requires laboratory testing on an
                              outpatient basis, a capitated laboratory should be utilized whenever
                              possible.
                              The capitated laboratory will conduct an office orientation and
                              establish an account with the physician office.
                              Accurate billing is improved by ensuring the following information in
                              included on the laboratory requisition form.
                                  o   Patient name (as it appears on the member ID card)
                                  o   Member ID Number
                                  o   Patient Address
                                  o   Patient Date of Birth
                                  o   Patient Gender
                                  o   Patient IDC-9 code
  Physical Therapy            Primary care physicians may select a capitated physical therapy
                              provider when this program is available in your area.
                              The physical therapy provider will provide a full range of physical
                              therapy and occupational therapy services.
                              The capitation covers ages 12 and above. Children under age 12
                              may be referred to your capitated physical therapy provider or any
                              participating provider.
                              Please refer to the Aetna Referral Directory for the current list of
                              physical therapy providers.
                              If your market does not have a capitated physical therapy provider,
                              the member should be referred to a participating physical therapy
                              provider.
  Foot Care                   Primary care physicians may select only one Aetna participating
                              capitated foot care provider.
                              All foot care services must then be referred to the PCP’s capitated
                              provider.
                              Participating pediatricians may also select a capitated foot care
                              provider; however, foot care is not capitated for children under 12
                              years of age.




                                                III-3             Local Network Information - Northeast
                            Aetna Golden Medicare members are also capitated for foot care.
Radiology                   Radiology studies require an authorization or referral in
                            Massachusetts, Maine, Connecticut, New York and New Jersey.
                            Please see Region tab for further information.
                            Primary care physicians may select only one capitated radiology
                            provider. All nonemergent outpatient diagnostic radiology services
                            must then be directed to this radiology provider.
                            Capitated radiology services do not include stress thallium studies,
                            or obstetrical ultrasounds, and in some cases, MRI services.
                            Participating providers must be used when ordering any radiology
                            study. See your Aetna Referral Directory for a listing of these
                            locations.
                            Radiology studies, including MRI and MRAs, can be ordered by
                            either the primary care physician or participating specialist;
                            however, the member must be sent to the radiologist their PCP has
                            selected for capitated services.
                            The following vendors have been selected to provide imaging pre-
                            certification:
                                Vendor                  Service Area
                            Care Core Inc.              Metro New York and New Jersey *
                            Med-Solutions Inc.          Connecticut, Massachusetts and Maine
                                * Excluding Upstate New York (e.g., North and West of, and including
                                  Delaware, Greene and Columbia counties).
                            .
                            Please reference the market specific section in this Toolkit for state
                            specific quick reference guides that include county listings.


Please Note: If your area does not have access to capitated providers, the member should
always be referred to a participating provider. Please check your Aetna Physician Referral
Directory for a listing of participating providers.




                                                III-4             Local Network Information - Northeast
Chickering Student Health Program
  Aetna partners with The Chickering Group, our exclusive TPA for Student Health Plans, to
  provide health coverage for college students. These Student Health Plans are underwritten by
  Aetna, but administered by Chickering on a separate claim system, due to the intricacies of these
  plans.

  All Student Health Plans utilize our Aetna network and utilization review staff.

  Chickering handles provider service calls as well at 800-966-7772.

  For more information on Chickering, please visit their website at: www.chickering.com.

  Currently, claims are only accepted via paper by direct submission to:

                                        The Chickering Group
                                            PO Box 15708
                                       Boston, MA, 02215-0014

  Should you have questions or need clarification, please contact the number on the member’s ID
  card.




                                                  III-5            Local Network Information - Northeast
Physician Billable Services – HMO Plans

    Capitated Primary Care Physicians Only
    The Aetna capitation model expands the number of services for which Aetna will reimburse
    primary care physicians (PCPs) on a fee-for-service basis outside of the monthly capitation
    payment. For instance, fee-for-service payments will be made for minor surgical procedures,
    endoscopies, immunizations, fracture care, stat laboratory services and certain other office-
    based procedures in accordance with Aetna’s claims submission and adjudication policies
    and procedures.


    Limited In-Office Laboratory and Radiology Services
    All physicians may provide certain laboratory and radiology procedures in their office and
    these services will be reimbursed by Aetna on fee-for-service basis. This policy allows
    physicians who are properly certified to conveniently provide certain laboratory and radiology
    services on a stat or as needed basis within their offices.

    Please refer to the schedule previously distributed for details on these billable services. If
    needed, laboratory and radiology should be directed to contracted specialty sites. Referrals
    are not required in these circumstances.

    For further information on these policies, please contact Aetna provider services at 1-800-
    624-0756.




                                                III-6           Local Network Information - Northeast
                  GREATER METROPOLITAN NEW YORK
         CARE CORE NATIONAL and AETNA DIAGNOSTIC IMAGING PROGRAM
                         QUICK REFERENCE GUIDE

Phone Numbers:                                    Information required for a Complete
• CareCore Precert line:                          Precertification Request:
    1-888-622-7329 (8:00 am - 6:00 pm)            1. Patient Information:
• CareCore Customer Service:                      • Health Plan name
    1-888-622-7329 (8:30 am – 5:00 pm)            • Patient’s Aetna ID number
• CareCore fax line: 1-845-298-1490               • Patient name
• Aetna Provider Services:                        • Date of Birth
    1-800-624-0756                                • Address
Imaging Care Management                           • Telephone number
(Precertification):                               2. Medical Identifiers:
Required for each of the following procedures:    • Ordering physician’s name, specialty, address,
  CT Scans        Nuclear Medicine                    and telephone number
  MRI/MRA        Pet Scans                        • Facility to which the patient is being referred and
 (See complete list of CPT codes)                     its address
                                                  • The contact person at the ordering physician’s
Exclusions: Above procedures performed in             office
the following place of service:                   3. Clinical Information:
     • Inpatient setting                          • The examination(s) being requested, with the CPT
     • Emergency room                                 code(s)
     • Ambulatory surgery center (SPU)            • The diagnosis or “rule out” with the ICD-9 code(s)
                                                  • The patient’s symptoms, listed in detail, with
                                                      severity and duration. Any treatments that have
                                                      been tried, including dosage and duration for
                                                      drugs, and dates for other therapies.
                                                  • Any other information that the physician believes
                                                      will help in evaluating the request, including but
                                                      not limited to prior diagnostic tests, consultation
                                                      reports, etc.
                                                  • Dates of prior imaging studies performed.
Eligibility Verification:                         Claims Submission
Process below is detailed in the “Aetna           • All claims for radiology services will be submitted
Participating Physician Office Manual”                to Aetna as they are today.
                                                  • Physicians/radiology providers who are directly
Aetna ID Card                                         contracted with CareCore should bill them directly.
At each visit, the office should ask to see the   • All current reimbursement policies and procedures
member’s ID card to verify eligibility and to         will apply.
collect appropriate co-payment.                   • Any claims for services requiring a precertification
                                                      that has either not been obtained or was not
To Check Eligibility: Offices may use one of          approved in advance, will be denied
the following options                             • Services billed for any procedure (CPT code)
• VRU-Voice Response Unit                             other than those approved will be denied.
• POS/Genesis Device                              • Members must not be billed for any services
• Practice Management Software                        denied due to the lack of an approval or valid
• EDI Vendor Internet Portal                          precertification.
• Aetna’s Provider Relations Phone Line: 1-       • Obtaining an approved precert does not
    800-624-0756                                      guarantee payment. Claims payment is also
                                                      dependent upon the member’s eligibility and
                                                      benefit plan.
                                                  • Physicians and/or radiology providers should



                                                   III-7           Local Network Information - Northeast
                                                     contact either Care Core or Aetna at the numbers
                                                     listed above.
Service Area: Members residing in, but have       Complaints and or Grievance
not yet selected PCPs, as well as those who       • Members, physicians or radiology providers may
have selected PCPs located in the following          register a complaint with Aetna by calling Member
counties: Westchester, Manhattan, Bronx,             Services at the toll-free number on the Member’s
Kings (Brooklyn), Queens, Richmond                   Aetna ID card or Provider Services at 800 624-
(Staten Island), Nassau, Suffolk, Rockland,          0756.
Orange, Putnam, Dutchess, Ulster, and             • If the member/provider is not satisfied with the
Sullivan.                                            response received, the Member or Provider
                                                     Services staff can explain the Aetna grievance
Products Included: All HMO based plans               process that applies to their benefit plan.
including, but not limited to- HMO, QPOS®,
US Access®, Aetna Open Access™,
Individual Advantage, and
Effective 4/1/03: Aetna Golden Medicare
Plans®

Members Excluded: Certain multi-specialty
or IPA groups.
Imaging Care Management Process                   Imaging Care Management Review Outcomes:
Physicians will obtain a precert by contacting     • Approvals: Requests, which satisfy all of the
CareCore:                                            criteria for medical necessity, will be approved.
By phone: 1-888-622-7329 or                          Approvals will be communicated both telephonically
Fax: 845-298-1490 (fax form enclosed)                and in writing to the referring physician with an
• Physician must provide all information listed      accompanying authorization number
  on this card for a precert request to be
  reviewed.                                       • Withdrawal: In the event that the requesting
• The patient’s clinical history and diagnostic     provider agrees that the request for service is not
  information will determine if the requested       the appropriate exam, the requesting physician
  procedure meets the medical criteria for          may withdraw his/her request for clinical
  each procedure requested.                         certification.
• All decisions are made by licensed, health      • Written notification will be sent to the physician
  care professionals.                               acknowledging the withdrawal.
• Review determinations for non-urgent
  care will be completed within two (2)           Non-certified: (Adverse Determination) Studies that
  working days of receipt of all the              do not meet criteria for medical necessity will be
  necessary information.                          denied.
• Requesting physicians will be notified of       • Prior to a final decision being rendered additional
  review determinations (see outcomes               clinical information to support the medical necessity
  section).                                         of the procedure may be requested from the
Physician and radiology providers may verify        referring physician.
precert status by calling CareCore on the         • The requesting physician will be notified by
precert line above or over the Internet @           telephone as the patient designee. The patient and
www.carecorenational.com                            physician are notified by mail, as required by law,
                                                    of the adverse determination.
Urgent Cases:                                     • Notification will include information as to why the
Physicians may request authorization on an          procedure was denied and what appeal rights the
urgent basis if they determine it to be             member has.
medically required. Decisions will be rendered    • Reconsiderations: physicians who have additional
for urgent requests within three (3) hours of       information may request a reconsideration from
CareCore receiving all required information.        CareCore of the adverse determination.
                                                  • Decisions may also be appealed as outlined below
Retrospective Reviews
If services are required on an urgent basis       • Appeals – Members, for whom a procedure has



                                                   III-8           Local Network Information - Northeast
and authorization cannot be obtained, the            been denied, have the right to appeal. Physicians
procedure may be performed, and an                   may also file an "appeal" (see appeal section)
authorization requested retrospectively.             regarding decision that request does not meet
• Requests for a retrospective review must be        criteria.
  made within two (2) business days of the             • Appeals may be initiated by the member, or the
  date of service.                                        referring physician on the member’s behalf
• Physicians should follow the same process            • The process for filing an appeal can be
  outlined above for a standard request.                  obtained by calling Aetna’s Member/Provider
• Documentation must include why the                      Services.
  procedure was required on an urgent basis.                o Provider Service- 1-800-624-0756
• Clinical justification for the request will be            o Member Services – 1-800-323-9930 or
  reviewed using the same criteria as a                          the number on the back of the member’s
  routine request.                                               card.
• Retrospective review decisions will be made          • Additionally, appeals can be filed by following
  within thirty (30) working days of receiving            the directions indicated on the denial letter.
  all necessary information. (Note: if the
  procedure does not meet medical necessity
  guidelines payment will be denied.)

  08.03.80.1-NY




                                                   III-9           Local Network Information - Northeast
                                      No. New Jersey
                                    NYMI now CareCore
                           AETNA DIAGNOSTIC IMAGING PROGRAM
                                QUICK REFERENCE GUIDE

Phone Numbers:                                    Information required for a Complete
• CareCore Precert line:                          Precertification Request:
    1-888-647-5940 (8:00 am - 6:00 pm)            1. Patient Information:
• CareCore Customer Service:                      • Health Plan name
    1-888-647-5940 (8:30 am – 5:00 pm)            • Patient’s Aetna ID number
• CareCore fax line: 1-845-298-1490               • Patient name
• Aetna Provider Services:                        • Date of Birth
    1-800-624-0756                                • Address
Imaging Care Management                           • Telephone number
(Precertification):                               2. Medical Identifiers:
Required for each of the following procedures:    • Ordering physician’s name, specialty, address,
  CT Scans        Nuclear Medicine                    and telephone number
  MRI/MRA        Pet Scans                        • Facility to which the patient is being referred and
 (See complete list of CPT codes)                     its address
                                                  • The contact person at the ordering physician’s
Exclusions: Above procedures performed in             office
the following place of service:                   3. Clinical Information:
     • Inpatient setting                          • The examination(s) being requested, with the CPT
     • Emergency room                                 code(s)
     • Ambulatory surgery center (SPU)            • The diagnosis or “rule out” with the ICD-9 code(s)
                                                  • The patient’s symptoms, listed in detail, with
                                                      severity and duration. Any treatments that have
                                                      been tried, including dosage and duration for
                                                      drugs, and dates for other therapies.
                                                  • Any other information that the physician believes
                                                      will help in evaluating the request, including but
                                                      not limited to prior diagnostic tests, consultation
                                                      reports, etc.
                                                  • Dates of prior imaging studies performed.
Eligibility Verification:                         Claims Submission
Process below is detailed in the “Aetna           • All claims for radiology services will be submitted
Participating Physician Office Manual”                to Aetna as they are today.
                                                  • All current reimbursement policies and procedures
Aetna ID Card                                         will apply.
At each visit, the office should ask to see the   • Any claims for services requiring a precertification
member’s ID card to verify eligibility and to         that has either not been obtained or was not
collect appropriate co-payment.                       approved in advance, will be denied
                                                  • Members must not be billed for any services
To Check Eligibility: Offices may use one of          denied due to the lack of an approval or valid
the following options                                 precertification.
• VRU-Voice Response Unit                         • Obtaining an approved precert does not
• POS/Genesis Device                                  guarantee payment. Claims payment is also
• Practice Management Software                        dependent upon the member’s eligibility and
• Web MD Office (internet)                            benefit plan.
• Aetna’s Provider Relations Phone Line:          • Physicians and/or radiology providers should
    1-800-624-0756                                    contact either their Professional Services
                                                      Coordinator (PSC) or Network Services
                                                      Coordinator (NSC) with any questions.



                                                  III-10           Local Network Information - Northeast
Service Area: Members enrolled to PCPs            Complaints and or Grievance
located in the following counties: Bergen,        • Members, physicians or radiology providers may
Essex, Hudson, Hunterdon, Middlesex,                  register a complaint with Aetna by calling Member
Monmouth, Morris, Ocean, Passaic,                     Services at the toll-free number on the Member’s
Somerset, Sussex, Union and Warren                    Aetna ID card or Provider Services at 800 624-
                                                      0756.
Products Included: All HMO based plans            • If the member/provider is not satisfied with the
including, but not limited to- HMO, QPOS®,            response received, the Member or Provider
US Access®, Aetna Open Access™,                       Services staff can explain the Aetna grievance
Individual Advantage, Golden Medicare Plans           process that applies to their benefit plan.
Imaging Care Management Process                   Imaging Care Management Review Outcomes:
Physicians will obtain a precert by contacting     • Approvals: Requests, which satisfy all of the
CareCore:                                            criteria for medical necessity, will be approved.
By phone: 1-888-647-5940 or                          Approvals will be communicated both telephonically
Fax: 1-845-298-1490 (fax form enclosed)              and in writing to the referring physician with an
• Physician must provide all information listed      accompanying authorization number
  on this card for a precert request to be
  reviewed.                                       • Withdrawal: In the event that the requesting
• The patient’s clinical history and diagnostic     provider agrees that the request for service is not
  information will determine if the requested       the appropriate exam, the requesting physician
  procedure meets the medical criteria for          may withdraw his/her request for clinical
  each procedure requested.                         certification.
• All decisions are made by a New Jersey          • Written notification will be sent to the physician
  licensed, board certified physician..             acknowledging the withdrawal.
• Review determinations for non-urgent care
  will be completed within two (2) working        Non-certified: (Adverse Determination) Studies that
  days of receipt of all the necessary            do not meet criteria for medical necessity will be
  information.                                    denied.
• Requesting physicians will be notified of       • Prior to a final decision being rendered additional
  review determinations (see outcomes               clinical information to support the medical necessity
  section).                                         of the procedure may be requested from the
Physician and radiology providers may verify        referring physician.
precert status by calling CareCore on the         • The requesting physician will be notified by
precert line above or over the Internet @           telephone as the patient designee. The patient and
www.carecorenational.com                            physician are notified by mail, as provided by law,
                                                    of the adverse determination.
Urgent Cases:                                     • Notification will include information as to why the
Physicians may request authorization on an          procedure was denied and what appeal rights the
urgent basis if they determine it to be             member has.
medically required. Decisions will be rendered    • Reconsiderations: physicians who have additional
for urgent requests within three (3) hours of       information may request reconsideration from
CareCore receiving all required information.        CareCore of the adverse determination.
                                                    Reconsiderations must be filed within 3 days of the
Retrospective Reviews                               notice of the denial. Physicians, who have
If services are required on an urgent basis         additional documentation to support the denied
and authorization cannot be obtained, the           request after the 3 days can appeal through the
procedure may be performed, and an                  Aetna appeals process.
authorization requested retrospectively.          • Decisions may be appealed as outlined below
• Requests for a retrospective review must be
   made within two (2) business days of the       • Appeals – Members, for whom a procedure has
   date of service.                                 been denied, have the right to appeal. Physicians
• Physicians should follow the same process         may also file an "appeal" (see appeal section)
   outlined above for a standard request.           regarding decision that request does not meet
• Documentation must include why the                criteria.
   procedure was required on an urgent basis.         • Appeals may be initiated by the member, or the



                                                  III-11           Local Network Information - Northeast
• Clinical justification for the request will be          referring physician on the member’s behalf
  reviewed using the same criteria as a                 • The process for filing an appeal can be
  routine request.                                        obtained by calling Aetna’s Member/Provider
Retrospective review decisions are made                   Services.
within thirty (30) working days of receiving all            o Provider Service- 1-800-624-0756
necessary information. However, in general,                 o Member Services – 1-800-323-9930 or
CareCore completes retrospective reviews                         the number on the back of the member’s
within 2 business days. (Note: if the                            card.
procedure does not meet medical necessity               • Additionally, appeals can be filed by following
guidelines payment will be denied.)                       the directions indicated on the denial letter.




                                                   III-12           Local Network Information - Northeast
Aetna Unique Specialty Providers – HMO and QPOS
Connecticut
  Laboratory: Quest
  This specified provider should be utilized for all laboratory services (primary and specialist
  requests). If the indicated laboratory provider is unable to perform a specific test, please have the
  member go to that provider anyway to have the blood drawn and have the lab determine which
  facility the sample should be sent to for testing. A referral is not necessary as long as the lab’s
  requisition form is utilized and the member presents an Aetna ID card.




                                                  III-13           Local Network Information - Northeast
Massachusetts and New Hampshire Immunization Policy
  As part of Aetna’s immunization program, we are committed to working closely with participating
  primary care physicians to improve the overall immunization rate for our pediatric membership.
  The states of Massachusetts and New Hampshire are universal vaccine distribution states that
  provide all recommended childhood vaccines free of charge, including tetanus-diphtheria (TD)
  vaccines, to their residents.

  Aetna reimbursement policy covers only the administration fee for recommended childhood
  vaccines and TD that can be supplied by either the Massachusetts Immunization Program (MIP)
  or the New Hampshire Immunization Program (NHIP).

  To enroll and obtain these free vaccines for your patients, please call one of the following,
  depending on your location:

                         Massachusetts Immunization Program – 617-983-6828.
                                            - OR -
                         New Hampshire Immunization Program – 603-271-4634

  In order to be reimbursed for the administration fee, please submit claims electronically or on a
  HCFA 1500 form with the appropriate vaccine code and our claim systems will reimburse you for
  the administration fee. Please note:
  • Claims for HMO members should be submitted to PO Box 1125, Blue Bell, PA 19422.
  • Claims for Non HMO Members (i.e. Open Choice, Managed Choice, Elect Choice and
      Traditional Choice) should be sent to the appropriate claim address listed on the back of the
      member’s ID card.

  Should you have questions on the above information, please contact Aetna provider services at
  1-800-624-0756.




                                                  III-14           Local Network Information - Northeast
Radiology Imaging Program: MedSolutions

                   Massachusetts / Maine / Connecticut
  Aetna Radiology Management Program: MedSolutions

  Aetna requires that all outpatient, elective MRI, MRA, CT scans, PET scans, and nuclear cardiac
  imaging studies demonstrate medical necessity through precertification with MedSolutions.
  Radiology procedures performed during an inpatient or emergency room visit do not require
  precertification with MedSolutions. Medical review can require 24 hours or one business day for
  completion. Please keep these time frames in mind when scheduling studies that require
  precertification.

  This program affects most Aetna HMO, QPOS®, Aetna Open Access™ HMO, Aetna Choice™
  POS and USAccess® members with a Maine, Massachusetts or Connecticut based Primary Care
  Physician.

  For those physicians participating with Aetna through an Independent Physician Association (IPA)
  Agreement, the precertification policy for members with a primary care physician associated with
  the IPA may differ. Please contact your contract negotiator or physicians relations liaison (PRL)
  for further details.

  Precertification Process

  There are three separate ways to request precertification of an imaging procedure from
  MedSolutions:

  1. Complete the Internet-based submission form by logging on to the secure website at
     www.medsolutions.com
          or
  2. A) Complete the demographics box at the top of the Universal CT/MRI form and include the
     office notes/previous imaging reports for the patient or
     B) complete the appropriate fax form by body part in its entirety, and fax to MedSolutions toll-
     free at 1-888-693-3210
          or
  3. Call MedSolutions toll-free at 1-888-693-3211 and give all pertinent clinical information over
     the telephone. When calling MedSolutions with a request for precertification, please have the
     following information available:

          •   Patient demographic information from the top of the fax form.
          •   Current diagnosis and clinical information, including treatment history, treatment plan
              and medications.
          •   The patient’s chart and previous imaging study results

  Approvals

  Your request for precertification will be processed within 24 hours or one business day after the
  receipt of all necessary clinical information. Once a requested procedure is approved, an
  authorization number will be faxed to the ordering physician and requested facility, and mailed to
  the member.




                                                 III-15           Local Network Information - Northeast
Denials

Prior to a denial, the ordering physician will be given an opportunity to discuss the treatment plan
and clinical basis for the request. If the requested procedure is then denied, a MedSolutions
representative will contact the ordering physician’s office and verbally communicate that the
procedure has been denied and the rationale for the denial. Written notification of the denial will
be faxed to the ordering physician and the facility requested to perform the procedure. The denial
determination will be mailed to the patient following the adverse decision. The written notification
will include details addressing the right to an appeal.

Denial Decision Physician Discussions

The treating physician may request to have a discussion regarding the denial decision for an
individual case with a MedSolutions’ physician reviewer by calling MedSolutions at 1-888-693-
3211.

Physician Consultations

MedSolutions has a staff of physicians that can be reached by phone to provide assistance in
determining the most appropriate imaging study for your patient. You can access this resource by
calling 1-888-693-3211 and pressing the option for physician consultation. Please be sure to have
the patient identification number and the applicable clinical information available at the time of the
call.

Medically Urgent Outpatient Procedures

For medically urgent services, call MedSolutions toll-free at 1-888-693-3211 for precertification.
Have the pertinent clinical office notes, the patient’s chart and previous imaging study results
available for reference during your call. MedSolutions will make a good faith effort to render a
medical necessity decision within 4 hours of receipt of all necessary clinical information. Please
clearly indicate that the precertification request is medically urgent.

Facilities/Radiologists

Please call MedSolutions at 1-888-693-3211 to verify the status of the request, if a member
presents for testing without proof of precertification. The precertification number should also be
entered on the billing form to ensure accurate payment of the claim.

MedSolutions Web-Based Services

You may access MedSolutions on-line for day-to-day transactions and services. To reach
MedSolutions on-line services, please go to the website, www.medsolutions.com and click the
MedSolutions Online link. Here you may sign up for access to a suite of MedSolutions services,
including precertification status inquiry and medical guidelines. Please click the “First Time User
Help” link for details about MedSolutions Online and how to become a member. Please be sure to
watch the website for news of future online initiatives.

Fax Forms

You can print additional copies of the fax forms for your use by accessing MedSolutions’ website
at www.medsolutions.com/faxforms.htm or by calling the MedSolutions Account Manager toll free
at 1-888-295-2954.




                                                III-16            Local Network Information - Northeast
Maine Chiropractic Care (Subluxation Benefits)
  For access to chiropractic care, the Aetna Health Inc.’s Chiropractic Care Benefit complies with
  Maine State mandate, as follows:

  A member may self-refer to a participating chiropractic provider, without a referral, if the member
  needs acute chiropractic treatment. “Acute chiropractic treatment” is defined as treatment by
  chiropractic provider for accidental bodily injury or sudden, severe pain that impairs the person’s
  ability to engage in the normal activities, duties or responsibilities of daily living. Self-referred
  acute chiropractic treatment is covered if all of these conditions are met:

      •   The injury or pain requiring acute chiropractic treatment occurs while the member’s
          coverage under the Aetna plan is in effect;
      •   Acute chiropractic treatment is provided by a participating chiropractor;
      •   The participating chiropractic provider prepares a written report of the member’s condition
          and treatment plan, including any relevant medical history, the initial diagnosis and other
          relevant information.

          Note: The chiropractic provider must send the report and treatment plan to the primary
          care physician within three (3) business days of the member’s first treatment visit. If the
          chiropractic provider does not follow this requirement, Aetna Health Inc. will not cover
          acute chiropractic treatment provided by the chiropractic provider, nor will the member be
          required to pay for services.

  Coverage for self-referred acute chiropractic treatment is limited to an initial maximum treatment
  period lasting until the last day of the third week from the member’s first treatment visit, or the
  twelfth treatment visit, whichever occurs first. At the end of this initial treatment period, the
  chiropractic provider will determine whether the services provided during this initial treatment
  period have improved the member’s condition. Aetna Health Inc. will not cover self-referred acute
  chiropractic treatment provided after the point at which the chiropractic provider determines that
  the member’s condition is not improving from the services. At this point, the chiropractic provider
  must discontinue treatment and refer the member to the member’s primary care physician. If the
  chiropractic provider recommends further acute chiropractic treatment, Aetna Health Inc. will
  cover this further treatment up to the limits specified below, but only if he or she sends a written
  progress report of the member’s condition and a treatment plan to the member’s primary care
  physician before any further treatment is provided. If the chiropractic provider fails to follow this
  requirement, Aetna Health Inc. will not cover any further acute chiropractic treatment in
  connection with the same illness or injury causing the member’s condition. The coverage for this
  further acute chiropractic treatment is limited to a maximum treatment period lasting until the last
  day of the fifth week from the member’s first further treatment visit, or the twelfth further treatment
  visit, whichever occurs first. Coverage for all self-referred acute chiropractic treatment is limited
  to a maximum of 36 treatment visits during any consecutive 12-month period.




                                                   III-17           Local Network Information - Northeast
Aetna’s Medicare+Choice Plans (NY & NJ)
  Aetna contracts with the Centers for Medicare & Medicaid Services (CMS) to offer two
  Medicare+Choice (M+C) plan options in five states for 2003, and, as such, it is an M+C
  organization (M+CO). The M+C plan options offered in 2003 are known as the “Aetna Golden
  Medicare Plan” (a managed care plan) and the “Aetna Golden Choice Plan” (an open access
  managed care plan with a point of service option). Generally, all M+C plans are required to offer
  Medicare basic benefits and follow both national and local coverage decisions.

  Members of the Aetna Golden Medicare Plan are required to select a primary care physician.
  Except for those benefits described in the member’s plan documents as direct access benefits
  and emergent or urgent care, members must have a referral from their primary care physician to
  receive coverage for any services the specialist or facility provides. (Offered in select counties in
  CA, NJ, NY, and PA.)

  Members of the Aetna Golden Choice Plan are not required to select a PCP or obtain a referral in
  order to obtain services from a network doctor, network specialist or network hospital. Aetna
  Golden Choice Plan members also have the option to select any non-network doctor, specialist or
  hospital for covered services without a referral. If exercising this option, they share the cost of
  their out-of-network medical expenses in the form of deductibles and coinsurances. (Offered in
  select counties in MD, NJ, and PA.)


  Physician/Health Care Professional Responsibilities & Important Information

  In accordance with M+C laws, rules and regulations, the following requirements apply to
  physicians or health care professionals (and their employees, independent contractors and
  subcontractors) contracting with a M+CO (“contracting providers”):

  Access to Facilities and Records
  M+C rules and regulations require that contracting providers retain and make available all records
  pertaining to any aspect of services furnished to M+C plan members for inspection, evaluation
  and audit for the longer of six years from the termination date of the provider’s contract with Aetna
  or the period required by law.

  Access to Services
  Aetna has procedures to:
      Identify members with complex or serious medical conditions;
      Assess those conditions, using medical procedures to diagnose and monitor them on an
      ongoing basis; and
      Establish a treatment plan with an adequate number of direct access visits to specialists
      (e.g., no prior authorization required) to comply with the treatment plan.

  Aetna’s contracting providers are required to make services available in a culturally competent
  manner to all M+C members, including those with limited English proficiency or reading skills,
  diverse cultural and ethnic backgrounds, and physical or mental disabilities. Aetna maintains
  procedures to inform members with specific health care needs of follow-up care and provide
  training in self-care, as necessary.

  Advance Directives
  Aetna’s contracting providers must document in a prominent place in an M+C member’s medical
  record whether the member has executed an Advance Directive. Please refer to the Member
  Rights and Responsibilities section for more information on Advance Directives.




                                                   -1-                    Aetna’s Medicare+Choice Plans
Appeals & Grievances
Aetna may require the cooperation and/or participation of contracting providers in Aetna’s internal
and external review procedures relating to the processing of Medicare appeals and grievances.

If necessary, the provider should instruct the member to contact the health plan for his or her
M+C appeal rights as well as inform the member of his or her right to receive, upon request, a
detailed written notice from the health plan regarding coverage for services. Members should be
directed to contact Member Services using the phone number listed on their ID card.

Confidentiality and Accuracy of Enrollee Records
Aetna’s contracting providers must safeguard the privacy and confidentiality of and assure
accuracy of any information that identifies a M+C plan member. Original medical records must
be released only in accordance with federal or state laws, court orders or subpoenas.

Aetna’s contracting providers must:
    Maintain accurate medical records or other health information,
    Help ensure timely access by members to the records and information that pertains to them,
    and
    Abide by all federal and state laws regarding confidentiality and disclosure of mental health
    records, medical records, other health information and member information.

Please refer to the Privacy Practices section for further information.

Coverage of Renal Dialysis Services for Medicare Members Temporarily Out of Area
An M+C plan member may be temporarily out of the service area for up to six months. M+COs
must pay for renal dialysis services obtained by an M+C plan member from a contracted or non-
contracted Medicare-certified physician or health care professional while the member is
temporarily out of the M+C plan’s service area.

Direct Access to In-Network Women’s Health Specialists
M+C members have direct access to mammography screening services at a contracted radiology
facility without a referral, as well as direct access to in-network women’s health specialists for
routine and preventive services.

Emergency Services
Please refer to the Office Management section for more information on Emergency Services.

Health Risk Assessment
Aetna performs an initial health risk assessment of each new M+C enrollee within 90 days of
enrollment in an Aetna M+C plan. A health risk assessment survey is completed by telephone for
all new M+C plan members. The information obtained through the survey is sent to the
member’s primary care physician.

No Cost-Sharing for Influenza and Pneumococcal Vaccines
M+C plan members are not required to pay an office visit copayment if the administration of an
influenza or pneumococcal vaccine is the only service provided.

Receipt of Federal Funds, Compliance with Federal Laws & Prohibition on Discrimination
Payments made by Aetna to a contracting provider for services rendered to an M+C member
constitute receipt of federal funds; therefore, an M+CO’s contracting providers are subject to: (1)
Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 84; (2) the
Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91; (3) the
Rehabilitation Act of 1973; (4) the Americans With Disabilities Act; and (5) all other laws
applicable to recipients of federal funds. In addition, Aetna’s contracting providers must comply
with all applicable Medicare laws, rules and regulations and they are prohibited from
discriminating against a M+C member on the basis of health status.



                                                 -2-                     Aetna’s Medicare+Choice Plans
Physician Terminations
CMS requires that M+C plans make a good faith effort to provide written notice of a termination of
a contracted physician at least 30 calendar days before the termination effective date to all
members who are patients seen on a regular basis by the physician (e.g., specialist) whose
contract is terminating. In addition, when a contract termination involves a PCP, all members
who are patients of that primary care professional must also be notified.

Financial Liability for Payment for Services
In no event shall an M+CO’s contracting providers bill an M+C member for payment of fees that
are the legal obligation of the M+CO. However, a contracting provider may collect deductibles,
coinsurance or copayments from M+C members in accordance with the terms of the member’s
agreement with Aetna.

Temporary Move Out of the Service Area
CMS defines a temporary move as (1) an absence from the service area (where the member is
enrolled in an M+C plan) of six months or less, and (2) maintaining a permanent
address/residence in the service area. An M+C plan member is covered out of the service area
for emergency, urgent, and out-of-area dialysis services. A member who moves out of the M+C
service area for over six months is disenrolled from the M+C plan.

Urgently Needed Services
Urgently needed services are covered services provided when a member is temporarily absent
from the plan’s service area (or, under unusual and extraordinary circumstance, provided when
the member is in the service area but the plan’s physician network is temporarily unavailable or
inaccessible) when such services are medically necessary and immediately required. The need
for such services could be the result of an unforeseen illness, injury, or condition, when it was not
reasonable, given the circumstances, to obtain the services through the health plan.

Physicians and Health Care Professionals & Marketing of M+C Plans
M+COs and their contracting providers must adhere to all applicable M+C laws, rules and
regulations relating to marketing. Per M+C regulations, “marketing materials” includes, but is not
limited to, promoting an M+CO or a particular M+C plan, informing Medicare beneficiaries that
they may enroll or remain enrolled in an M+C plan offered by an M+CO, explaining the benefits of
enrollment in an M+C plan or rules that apply to enrollees, or explaining how Medicare services
are covered under an M+C plan. Physicians and other health care professionals may discuss, in
response to an individual patient’s inquiry, the various benefits of M+C plans. Physicians and
health care professionals can refer their patients to 1-800-MEDICARE, the State Health
Insurance Assistance Program, the specific health plan M+C marketing representatives or CMS's
website at www.medicare.gov in order to obtain additional information. Physicians and health
care professionals cannot accept M+C plan enrollment forms.

Services Received Under Private Contract
Pursuant to the Balanced Budget Act of 1997 (BBA), physicians may “opt out” of participating in
the Medicare program and enter into private contracts with Medicare beneficiaries. If a physician
chooses to opt out of Medicare due to private contracting, no payment can be made to that
physician directly or on a capitated basis for Medicare-covered services. The physician cannot
choose to opt out of Medicare for some Medicare beneficiaries but not others, or from some
services but not others. The M+CO is not allowed to make payment to any physicians or health
care professionals who have opted out of Medicare due to private contracting, unless the
beneficiary was treated for urgent or emergent care.

Claims/Billing Requirements
Physicians and health care professionals must use valid International Classification of Disease,
9th Edition, Clinical Modification (ICD-9 CM) codes and code to the highest level of specificity.




                                                -3-                    Aetna’s Medicare+Choice Plans
Complete and accurate use of CMS’s Healthcare Common Procedure Coding System (HCPCS)
and Common Procedural Terminology, 4th Edition, (CPT) procedure codes are also required.

Hospitals and physicians using the Diagnostic Statistical Manual of Mental Disorders, 4th Edition,
(DSM IV) for coding must convert the information to the official ICD-9 CM codes. Failure to use
the proper codes will result in diagnoses being rejected in the Risk-Adjustment Processing
System. The ICD-9 CM codes must be to the highest level of specificity: assign three-digits
codes only if there are no four-digit codes within that code category, assign four-digit codes only if
there is no fifth-digit sub-classification for that subcategory, assign the fifth-digit sub-classification
code for those subcategories where it exists.

Report all secondary diagnoses that impact clinical evaluation, management and/or treatment.
Report all relevant V-codes and E-codes pertinent to the care provided. An unspecified code
should not be used if the medical record provides adequate documentation for assignment of a
more specific code.

Failure to use current coding guidelines may result in a delay in payment and/or rejection of a
claim.

Submission of Medicare Claims and Encounter Data
The BBA mandates M+COs to collect and submit claims and encounter (risk-adjustment data) to
CMS that is received from hospitals, outpatient departments, physicians and certain non-
physician practitioners. Prior to 2002, CMS only collected inpatient hospital claims and
encounters from the health plans. Physicians and health care professionals are required to
submit accurate, complete and truthful data to the M+COs.

Risk-adjustment data submitted will determine risk-adjusted premium payments from CMS to the
M+COs. Prior to the enactment of the BBA, the payment rate was 100 percent demographic.
Beginning January 2000, the payment model changed to a blended rate of 10 percent risk
adjustment and 90 percent demographic. This blended rate will continue through 2003. The
percentage of risk-adjusted payments will increase to 30 percent in 2004, 50 percent in 2005, 75
percent in 2006 and full risk adjustment of 100 percent in 2007 and succeeding years. The lack
of risk-adjustment data may affect the premium to the M+CO and the physician or health care
professional organizations delegated for claims processing.

M+COs began submitting risk-adjustment data to CMS after October 1, 2002, for dates of
services beginning July 1, 2002, through June 30, 2003. This will determine the payments for
2004.

Co-existing Conditions
The ICD-9 CM guidelines for co-existing conditions that should be coded for hospital outpatient
and physician services are as follows:

  “Code all documented conditions that coexist at time of encounter/visit, and
   require or affect patient care treatment or management. Do not code
   conditions that were previously treated and no longer exist. However, history
   codes (V10-V19) may be used as secondary codes if the historical condition or
   family history has an impact on current care or influences treatment.”




                                                   -4-                    Aetna’s Medicare+Choice Plans
Physicians and hospital outpatient departments shall not code diagnoses documented as
“probable,” “suspected,” “questionable,” “rule out,” or “working” diagnosis. Rather, physicians and
hospital outpatient departments shall code the condition(s) to the highest degree of certainty for
that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Medical Record Validation
CMS will conduct a medical record review to validate the accuracy of the risk-adjustment data
submitted by the M+CO. The medical records shall agree to the diagnoses of the hospital
outpatient and physician diagnoses provided to the M+CO. The medical record shall be
retrievable to validate the diagnosis reported. CMS anticipates adjusting payments to M+COs as
a result of up coding or down coding with the results of the calendar year 2003 data validation.

Providers of Hospice-Related Services
Aetna Golden Medicare Plan and Aetna Golden Choice Plan members may elect to use the
hospice benefit in the Original Medicare program instead of their HMO or POS Medicare
coverage. Prior to initiating hospice care, the "Election of Benefits" waiver must be signed by the
member or his/her representative. When this election is documented, the case should be
referred to the Original Medicare hospice provider. Original Medicare will assume financial
responsibility on the date the waiver is signed, and reimbursement will be made by Original
Medicare directly to the agency. DME will be the responsibility of the hospice provider.

The M+C plan remains responsible for payment of those services not related to the terminal
illness and additional benefits not covered by Medicare. An example of an additional benefit is
the eyeglass reimbursement.

For services not related to the terminal illness, inpatient services should be billed to the Medicare
Fiscal Intermediary using the condition code 07.

For physician services and ancillary services not related to the terminal illness, the physician or
other health care professional should bill the Medicare Carrier (as is done for Medicare FFS
patients) and use the modifier GW.

Attending physician services are billed to the Medicare Carrier with the “GV” modifier, provided
they were not furnished under a payment arrangement with the hospice. If another physician
covers for the designated attending physician, the services of the substituting physician are billed
by the designated attending physician under the reciprocal or locum tenens billing instructions. In
such instances, the attending physician bills using the “GV” modifier in conjunction with either
“Q5” or “Q6” modifier.

Mandatory Generic Drugs (for those members with this benefit)
   Benefits vary across plan designs.
   Generic medications are required when available.
   If a physician believes the member requires a brand-name drug and the physician obtains
   approval from Aetna Pharmacy Management, the member is only responsible for the
   applicable brand-name copayment and not the difference in cost between the brand-name
   and generic drugs. Only physicians can obtain this approval; pharmacists are not eligible to
   request approval.

M+C Organization Obligations
The M+CO is prohibited from restricting a physician or health care professional from advising
his/her patients about their health status, treatment options, the risks and benefits of those
treatment options, and the opportunity to refuse treatment and/or express preferences about
future treatment decisions.




                                                 -5-                   Aetna’s Medicare+Choice Plans
Medicare+Choice Member Appeal Rights

As a member of the M+C plan, a member has the right to appeal any decision about the plan’s
failure to pay or provide coverage for what the member believes are covered benefits and
services (including non-Medicare covered benefits).

The M+C plan has both standard and expedited M+C appeals procedures. Decisions that are
commonly appealed include:
   Disputes involving payment for coverage of temporarily out-of-area renal dialysis services,
   emergency services, post-stabilization care or urgently needed services.
   Disputes involving payment for any other health services furnished by a provider or supplier
   that the member believes are covered by Original Medicare or, if not covered by Original
   Medicare, should have been reimbursed by the M+C plan.
   Disputes involving failure of the M+C plan to approve, furnish, arrange for or provide
   coverage for health care services in a timely manner, or to provide the member with timely
   notice of an adverse determination, such that a delay would adversely affect the member’s
   health.
   Discontinuation of coverage of a service, if the member disagrees with the determination that
   the coverage of service is no longer medically necessary.
   When rights claimed by a member regarding Medicare covered services covered by the M+C
   plan are denied, resulting in a dispute that places financial liability on the member.

Who May File an Appeal
1. A member
2. The legal representative of a deceased member’s estate
3. Someone else may file the appeal for a member on his/her behalf. A member may appoint an
   individual to act as his/her authorized representative to file the appeal for them by following
   the steps below:
   a. Give the M+C plan the member’s name, Medicare number and a statement that appoints
       an individual as the member’s representative.




               Note: A member may also appoint a physician.



   b. The member must sign and date the statement.
   c. The member’s representative must also sign and date this statement unless he/she is an
        attorney.
   d. The member must include this signed statement with their appeal.
4. A non-contracted physician or other provider who has furnished the member a service may
   file a standard appeal of a denied claim if they complete a waiver of payment statement that
   says they will not bill the member regardless of the outcome of the appeal.

M+C Standard Member Appeals
The M+C plan must notify the member in writing of any adverse decision (partial or complete).
The notice must state the reasons for the denial and also must inform the member of his/her right
to an appeal as well as the entire appeals process, including expedited appeals (for denials of
requests for services). The member must submit a written request for an appeal to the M+C plan.
The member should refer to their Evidence of Coverage for the appropriate M+C plan Medicare
Grievance and Appeals Unit address. The member may also request an appeal through the
Social Security office (or, if the member is a railroad retirement beneficiary, through a Railroad
Retirement Benefits Office). The member must submit the written request within 60 calendar
days of the date of the notice of the initial decision.


                                               -6-                   Aetna’s Medicare+Choice Plans
The M+C plan will conduct an appeal and notify the member in writing of the decision, using the
following timeframes:
     Request for Service. If the appeal is for a denied service, the M+C plan must notify the
     member of the reconsideration decision as expeditiously as the member’s health requires,
     but no later than 30 calendar days from receipt of the request. The M+C Plan may extend this
     timeframe by up to 14 calendar days if the member requests the extension or if the plan
     needs additional information, and the extension of time benefits the member.
     Request for Payment. If the appeal is for a denied claim, the M+C plan must notify the
     member of the reconsideration determination no later than 60 calendar days after receiving
     the request for a reconsideration determination.

M+C Expedited Member Appeals
A member has the right to request and receive expedited decisions affecting coverage of their
medical treatment in time-sensitive situations.

An expedited appeal is:
    an oral or written request from an Medicare member, their authorized representative or a
    physician (either contracted or non-contracted) for an expedited review of a determination by
    the M+C plan not to provide coverage of services that the member believes they are entitled
    to receive, including delay in providing, arranging for, or approving the health care services
    (such that a delay would adversely affect the member’s health); or of a determination to
    discontinue services when the member believes there is a continuing need for the service.
         AND,
    the Medicare member, their authorized representative or physician (contracted or non-
    contracted) believes the member’s health, life or ability to regain maximum function could be
    jeopardized by the standard 30 calendar day reconsideration process.

The process of review and decision is conducted as expeditiously as the member’s health
requires, not to exceed 72 hours. The M+C plan may extend the 72 hour deadline by up to 14
calendar days if the member requests the extension or if the M+C plan justifies a need for
additional information and the delay is in the interest of the member.

How to Request an M+C Expedited Member Appeal
To request an expedited appeal, the member, their authorized representative or a physician
(contracted or non-contracted) may call, write, fax or visit the M+C plan. Telephonic requests are
accepted 24 hours a day, 7 days a week. The 72-hour timeframe commences with the M+C
plan’s receipt of the request.




                                               -7-                   Aetna’s Medicare+Choice Plans

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:2325
posted:8/10/2011
language:English
pages:24
Description: Sample Referral Letter from Physical Therapist to Doctor document sample