Aetna Market Fee Schedule Update – April 15, 2023
Starting April 15, 2023, Aetna is adjusting their standard fee schedule (the Aetna Market Fee Schedule, or AMFS) for all plans in your Aetna service area. This change affects those services for which which they pay you, based upon the AMFS. You can find these services in the compensation section of your contract. Refer to the enclosed fee schedule for an example of these changes.
How Aetna Determines their Fee Schedule
- For Current Procedural Terminology (CPT) codes, they look at industry-standard methodologies and souraces, such as the 2023 Resource-Based Relative Value Scale (RBRVS). This include Outpatient Prospective Payment System (OPPS) rates that CMS establishes (CMS Clinical Laboratory Fee Schedule).
- For codes using RBRVS, Aetna uses the “site-of-service” differential. CMS defines this in transitional relative value units. This differential adjusts payment for certain codes bbased on where you perform a service. To find code-specific information where we they use RBRVS, and the 2022 formula for calculating the physician fee scheduel, visit (CMS.HHS.gov).
- For codes where the RBRVS process is either not used or not available, Aetna uses other sournces to develop fee schedules. This includes external vendor pricing modeils, Medicare fee schedules, and nationally contracted rates.
Updates for Immnunizations and Injectable Drugs
The AMFS wil show the rates that were in effect at the time the schedule was created. The rates will be updated in January, April, July, and October.
Adding new CMS Codes
Aetna will add new codes introduced by CMS to the AMFS. This will be done quarterly (January, April, July, and October).
You can see the Fee Schedule Online
The fee schedule will be online beginning April 15, 2023. Go to Aetna’s provider portal, Availity.com. Choose Claims & Payments, then Fee Schedule Listing on the far right.
You can also fax a fee schedule request before April 15, 2023. You can request up to 25 codes. Fax you request to the Provider Service Center at 1-859-455-8650.
Additional Help
If you have questions, call Aetna at:
- 1-800-624-0756 (TTY: 711) for health maintenance organization (HMO)-based and Medicare Advantage plans
- 1-888-MDAetna (1-88-632-3862) (TTY:711) for all other plans
Cigna’s Name is Evolving
On February 14, 2023, Cigna became Cigna Healthcare. This evolution of their brand signifies their renewed focus as an advocate for better health through every stage of life, as well as for improving the health, well-being, and peace of mind of their customers – your patients. Together, Cigna Healthcare and Evernorth Health Services will comprise The Cigna Group, a global health company committed to creating better health for all.
One of Cigna Healthcare’s core focuses will be to help guide our customers through the health care system by providing them with the information and insights they need to make the best choices for improving health and vitality. And because guiding our customers through this journey is not possible without a robust provider network, we strive every day to partner with you to create innovative programs, streamlined processes, and enhanced digital solutions to ensure that you remain empowered to provide the care you want to.
What this means to you
Your day-to-day business with us – including contracts, reimbursement, and network status – will remain the same. Only the Cigna Healthcare name and logo will change. You will start to see the new name and logo in communications and websites, and at events over the course of 2023 and beyond.
Going forward, your partnership will continue to be key in improving the health of our customers. Working together, we will help the people we serve have access to the very best care.
COVID-19 Public Health Emergency Expires May 11, 2023
The Covid-19 PHE will end on May 11, 2023. However, this does not mean that all telehealth flexibilities end on this date. Some of the flexibilities that were created during the pandemic were recently expanded by the Consolidated Appropriations Act of 2023 and will now extend until December 31, 2024.
Major Medicare telehealth flexibilities will not be affected. The vast majority of current Medicare telehealth flexibilities that Americans—particularly those in rural areas and others who struggle to find access to care—have come to rely upon over the past two years, will remain in place through December 2024 due to the bipartisan Consolidated Appropriations Act, 2023 passed by Congress in December 2022.
Medicaid telehealth flexibilities will not be affected. States already have significant flexibility with respect to covering and paying for Medicaid services delivered via telehealth. State requirements for approved state plan amendments vary as outlined in CMS’ Medicaid & CHIP Telehealth Toolkit (PDF). This flexibility was available prior to the COVID-19 PHE and will continue to be available after the COVID-19 PHE ends. Similar to Medicare, these telehealth flexibilities can provide an essential lifeline to many, particularly for individuals in rural areas and those with limited mobility.
For a complete roadmap of what will and will not be affected at the end of the PHE, please click here.
Excellus BCBS Clinical Editing Claims Processing Enhancement for All Lines of Business
Based on feedback from participating providers, Excellus BCBS will be moving post payment audit recovery for Administrative Policy 31- Related Services, to a prepayment clinical edit. This update will pertain to all lines of business.
This update will allow for more accurate editing related to the code descriptors of a procedure, such as frequency limitations. We will provide additional information on this update prior to implementation.
Important Reminders:
- A service that has already been reimbursed can cause a service on a subsequent claim to be disallowed, regardless of which service is considered primary. As a result, you may see a difference in how an edit is applied when services are on the same claim versus on different claims. To avoid out-of-sequence editing:
- Services performed on the same day should be submitted on the same claim.
- Services performed on different days may continue to be submitted on separate claims, but must be received and processed in date of service order.
- To dispute a clinical editing denial, a Clinical Editing Review Request form is no longer required. Simply correct your claim electronically on their website, Provider.ExcellusBCBS.com > Claims & Payments tab.
- Administrative and clinical editing policies are accessible on their website, Provider.ExcellusBCBS.com > Policies & Guidelines tab (Secure log-in required).
Excellus BCBS Preauthorization Updates Effective May 1, 2023
Updates to the preauthorization requirements under the Utilization Management (UM) Program will take place on May 1, 2023.
For details on preauthorization updates effective May 1, 2023, click here.
Each preauthorization update, effective May 1, 2023, will be highlighted in gray.
Please keep in mind that failure to follow UM policies and procedures, including failure to obtain preauthorization when required and failure to comply with your provider agreement or our member contract requirements, may result in claim denial or reduction in payment.
Courtesy Preauthorization
Courtesy preauthorization is available, at our discretion, for select services and product lines.
InterQual® Updates
Excellus will update InterQual information on their website when it becomes available. You will receive advance written notice regarding the effective date of any InterQual updates or revisions.
Medical Necessity
As Excellus updates their UM programs, they will implement additional retrospective reviews as needed using medical necessity post-service reviews or medical necessity audit(s), in lieu of preauthorization. Please be aware that these audits or reviews may be conducted post-service prior to payment or post-payment. As part of the UM retrospective review program, they will implement select medical necessity audits throughout 2023 and will provide notice of any additional details. They are mindful of the impacts to our providers as we strive to manage medical expense to meet our responsibility to our members and employer groups.
Durable Medical Equipment (DME)
Claims will deny or suspend for medical necessity review across all lines of business if preauthorization for applicable DME is not obtained. The current list of DME requiring preauthorization is here.
Medicare Line of Business
Excellus follows the CMS coverage guidelines for their Medicare Advantage line of business. These policies are located at cms.gov.
Molina Healthcare – Changes to Prior Authorization Requirements
Molina Healthcare of New York, Inc. is introducing changes to our current prior authorization requirements — the codes listed on this grid will now require that prior authorization be obtained by the provider. These changes will take effect on 3/1/23.
The Codification Matrix and Code LookUp Tool on their website will be updated and posted with the applicable changes effective 3/1/23.
Have you Received a Comparative Billing Report from NGS?
- CBRs are free
- CMS defines a CBR as an educational resource and a tool for possible improvement.
- CBRs are often used to alert providers if their billing statistics appear unusual compared to their peers.
- The CBR is an educational tool to support the effort of safeguarding the Medicare Trust Fund.
Comparative Billing Reports (CBRs) provide comparative data on how an individual provider compares to other providers. The data looks at billing patterns for these services. The CBR offers the results of statistical analyses that compare an individual provider’s billing practices for a specific code with the billing practices of that provider’s peer groups as well as national averages.
If you received a CBR, it simply means that through data analysis National Government Services has identified your billing as being significantly different when compared to your peers. You may contact the Medical Review Case Management team with any questions or concerns regarding your CBR. Use the email address found within your CBR to contact a Case Manager.