Payer Roundup, December 2017

In case you missed these — here is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit for more resources and information.


Aetna OfficeLink Updates notices going digital: Instead of postcard notifications, Aetna will send you an email reminder when a new edition of its quarterly newsletter is online at You’ll need to sign up before Jan. 31 to get the reminders. Sign in to NaviNet, and choose “Email Options” (under the Workflows for This Plan menu on Aetna Plan Central) and then “Share Email Address.”

Start submitting precertification requests electronically: In 2018, precertification requests to Aetna will be digital only (see the exception below). To submit electronic precertification requests, pick a vendor from Aetna’s list of approved vendors, or register for NaviNet — even if you’re a not a participating Aetna physician, you can register for limited access to Aetna’s secure provider website. Aetna says it soon will introduce a way for practices to upload documents electronically through NaviNet as well. If you need help, register for a webinar to learn how to submit precert requests electronically.

Note: In accordance with Medicare regulations, Aetna will continue to accept precertification requests initiated by phone for members enrolled in Medicare plans.

December policy change revision: Aetna recently announced that starting Dec.1, it would limit coverage for hospital professional services to once per day, per patient, for all physicians. However, Aetna now says it won’t apply the policy to critical care services (99291-99292), nor will the policy apply to hospital admission services (99221-99223) for nonparticipating physicians for Aetna Medicare Advantage plans.

Multiple procedure reductions: Starting March 1, Aetna will apply multiple procedure reductions of 20 percent for:

  • Diagnostic cardiology services, and
  • Diagnostic ophthalmology services.

This change does not apply to the service with the highest relative value unit (RVU) rate. It applies to the technical component of the RVU only, for services on the same date of service, billed by a single provider, and billed for the same patient.

 Aetna also will apply multiple procedure reductions to certain therapy services effective March 1. Aetna will pay 100 percent of a therapy service the highest practice expense (PE) RVU, and reduce the PE RVU portion of the total RVU by 50 percent for more therapy services performed on the same day.

Payment for incidental services: Starting March 1, Aetna will not pay for Healthcare Common Procedure Coding System codes C2617, C2625, C1752, C1769, C1770, C2623, and C1884 because these items are considered incidental. Aetna’s standard payment policies do not cover services considered incidental to the overall episode of care. This includes supplies; materials; and equipment such as sutures or suture substitutes, dressings, syringes, gauze, catheters, guide wires, stationary devices, and parenteral infusion pumps.

MNS contract to end: Effective Jan. 1, Management and Network Services (MNS) LLC, which coordinates the skilled nursing services for credentialing and also manages authorizations or claims payments, no longer will be an Aetna-contracted provider. This change affects all patients enrolled in Aetna and/or Coventry Medicare and in commercial or network access business (First Health, auto, or workers’ compensation) lines of business. For dates of service on or after Jan. 1, submit all patient claims directly to Aetna and/or Coventry. See the back of the member’s ID card for the correct address or claims-payer ID number.

New referral message in effect: Aetna’s policy is that you must make all referrals to physicians and providers that participate in a member’s specific benefits plan. Aetna has added a new denial message to clarify this, as follows:

“The referred-to provider ID utilized is not participating in this member’s specific network. Resubmit using a different referred-to provider ID. Access the Aetna website in the Healthcare Professionals section to find a participating provider for this member’s plan.”

 Source: Aetna OfficeLink Updates, December 2017

Humana Military

Referrals, authorizations during the transition. On Jan. 1, Humana Military becomes the payer for the new TRICARE East Region, consisting of the current TRICARE North and South regions. Humana Military says any carry-over referrals and authorizations, approved before Dec. 31, 2017, are still good in 2018. Prior authorization from Humana Military is required for some procedures and services on its prior authorization list. Here is a tip sheet from the payer.


Payment reduction for computed radiography: Starting Jan. 1 and extending through Dec. 31, 2022, Medicare will reduce by 7 percent payment for the technical component (and the technical component of the global fee) for computed radiography services, defined as cassette-based imaging. For such x-ray services furnished in 2023 and beyond, the payment reduction will be 10 percent. You must use new modifier FY on claims for the technical component of these x-ray services. For more information, see the Centers for Medicare & Medicaid Services’ (CMS’) MLN Matters No. MM10188.

No more hard-copy remittance advice: Beginning Jan. 2, if you’ve been a Novitas Solutions electronic data interchange (EDI) user for 45 days or more, you’ll no longer be able to get a hard copy of the Medicare remittance advice, only the electronic remittance advice. After Feb. 14, no EDI users will get the hard copy, unless this requirement causes hardship and CMS has approved a waiver requested by Novitas. For more information, see MLN Matters No. MM10151.

Physician Compare updates: If you anticipate needing to update your general information on Physician Compare, such as an address or phone number, remember it can take two to four months for the changes to show up on that website after you’ve entered them into Medicare’s Provider Enrollment, Chain, and Ownership System. Visit the Physician Compare Initiative webpage for information about this program.


Referral submission versus notification and prior authorization submission: Here’s a reminder about the differences among these types of requests.

 For health plans with referral requirements, the patient’s assigned primary care physician coordinates the patient’s care and submits electronic referrals to UnitedHealthcare (UHC) before the patient sees another network physician. To request a referral:

  • Via electronic data interchange: Use the 278 Authorization and Referral Request transaction, or
  • Online: The online tool varies with the member’s plan.

Advance notification is the first step in coverage determination and for recommending case and condition management programs. It’s part of UHC’s Medical Management Program. To request notification:

  • Via EDI: Use the 278N Hospital Admission Notification transaction, or
  • Online: Submit it through Link using the Notification and Prior Authorization app.

When prior authorization is required, UHC verifies whether the services are medically necessary, covered under the member’s plan and performed at the most appropriate setting for the patient. It’s also part of UHC’s Medical Management Program. To request prior authorization: 

  • Via EDI: Use the 278 Authorization and Referral Request transaction, or
  • Online: Submit it through Link using the Notification and Prior Authorization app.

 UHC says the easiest way to determine the correct online submission method is to look up the patient in eligibilityLink. You’ll see whether a referral is required, and you can click on the Referrals link to open the correct submission tool.

 Policy updates: UHC has announced three new drug policies:

 Also be sure to see UHC’s November 2017 Medical Policy Update Bulletin, which lists updated, revised, retired, and replaced medical and drug policies, and coverage determination guidelines, with effective dates of Nov. 1 and Dec. 1, 2017, and Jan. 1, 2018.

Source: UHC Network Bulletin, December 2017

Published Dec. 18, 2017

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Last Updated On

December 18, 2017

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