News Update

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Https // It’s as easy as 1, 2, and 3 to join the Aetna® network. We’ve included some helpful ideas if you don’t like doing paperwork. The first step is to invite people to participate. To get started, select one of the provided links. Throughout the Examination, a current need to serve our members in your area will be reviewed. If you are eligible to participate, we will notify you within 45 days for your convenience.

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Examine the terms of your agreement in the second phase

Once you’ve requested to join, you’ll be issued a contract to review. When you’ve signed it, please return it to us. After we receive your signed agreement, we will re-evaluate the deal. Once your contract has been reviewed and authorized, it will be returned to you. If you haven’t received your contract yet, please check your spam folder. Keep in mind that this isn’t the final step. You are not automatically added to our network after signing a contract. The next step in the process is credentialing.

The third step is to obtain full Certification

Your credentialing application will be received by the Council for Affordable Quality Healthcare’s ProView® (CAQH)*, which will begin the credentialing process. This stage can take anywhere from 45 to 180 days, depending on the status of your CAQH application and if you’ve given Aetna permission to read it. Aetna must have been given access to your application and your CAQH attestation must not have expired. This will speed up the procedure. You’ll be notified in writing when your certification is complete.

It’s vital to grasp the differences between accreditation and contracting. Both must be met before being admitted into the network. After you’ve completed both stages, your network representative will tell you of your participation’s start date. If you want to join a group that already exists, you should confirm the effective date of your participation with the group administrator.

Welcoming you to the Aetna family!

Congratulations! We look forward to collaborating with you to safeguard your patients’ health, safety, and well-being. You will receive your welcome materials as soon as possible. Aetna is the brand name used by a number of the Aetna group’s subsidiary companies, such as Aetna Life Insurance Company and its affiliates, to market their products and services (Aetna). This information is being provided as a courtesy only. Basic health information is provided by health information programs, but they are not intended to replace medical diagnosis or treatment. We cannot guarantee the correctness of this material, despite our best efforts.

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Health benefits and insurance policies are riddled with exclusions and limitations. Thank you for your interest in becoming a part of Aetna’s large network of physicians and health care professionals dedicated to assisting people on their path to better health. Thank you for expressing an interest in joining our community!

Participation Request Disclaimer

If you have any queries concerning our application or certification process, please use the link below. The websites of ProView® and Medversant’s ProviderSourceTM are also helpful places to explore healthcare cost information (for practitioners located in Washington state ). We get your credentials from many sources for doctors in Arkansas and Minnesota who are part of the Allina Health | Aetna joint venture network. You can amend any information obtained throughout the credentialing process by working directly with reporting firms.

When does precertification become necessary?

An organization determination can be requested by Medicare Advantage members, their designated representatives*, or physicians who need help making a coverage decision. To submit precertification via electronic data interchange, utilize our secure provider website or the phone number on the member’s ID card (EDI). Precertification is a process that takes place before some inpatient and outpatient operations and services begin. The following items require precertification:

  • Procedures and services on the Aetna Participating Providers Precertification List.
  • Procedures and services on the Aetna Behavioral Health Precertification List
  • Precertification is required for procedures and services that a member’s plan covers.

Precertification has a number of Advantages

You and our members (and their designated representatives) shall be informed of coverage choices before treatments, services, or supplies are provided. We can identify and enroll in special programs such as case management and disease management, behavioral health, and the National Medical Excellence Program (NMEP). Requests for information concerning benefits or services that are not on the precertification list for a specific member’s plan are typically not included in the precertification procedure. Aetna staff are trained to distinguish between queries and requests for coverage decisions/organizational judgments during the intake process.

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“Coverage” relates to whether a service or treatment is covered under the terms of a member’s benefits plan if a provider is contractually compelled to comply with Aetna’s utilization management programs, and whether the service or treatment is paid for under the terms of the provider agreement.

More stringent state criteria may outweigh our precertification requirements

The Centers for Medicaid and Medicare Services (CMS) uses the term “representative” to describe a person who has been nominated by a person involved in a grievance or appeal, or who is entitled to represent that person under applicable state or federal law. Unless otherwise noted, the representative will manage organization determinations, filing grievances, and deal with any level of the grievance or appeals process in accordance with the applicable regulations of 42 CFR 422 Subpart M. A representative form must be signed and dated by both the member and the member’s selected representative, according to CMS.

Name of the Service Provider’s Organization (NPI)

Health information may be exchanged more rapidly and securely over the internet with the National Provider Identifier (NPI). The numbers you may have previously provided to payers are no longer required for electronic claims, certifications, or authorization transactions. This list of payer numbers includes Medicare and Medicaid information.

What may my National Provider Identifier be used for?

Health care providers must use their National Provider Identifier (NPI) in electronic transactions under the 1996 HIPAA Act (HIPAA). Another reason healthcare providers need an NPI is so that electronic transactions from other organizations can identify them. For example, pharmacies must submit claims using the prescribing physician’s NPI. In order to electronically file claims, health care providers also require the NPIs of referring physicians.

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Is the NPI a substitute for a taxpayer identification number?

The billing provider’s TIN and NPI must always be included on claims. Other providers listed in the claim, such as a rendering service or a service facility, must only be identified by their NPI number. It is not necessary to include the TIN. For eligibility, claim status inquiry, referral, or precertification, no other identifier can be used. The provider’s NPI must be entered into our provider database. We’d like to know whether Aetna keeps old provider ID numbers or creates new ones. Yes. Our provider ID numbers haven’t changed in a long time. They’re used in another process.

Is it legal for service providers to communicate other kinds of identification in electronic transactions, such as PIN, PVN, and TIN?

Any health care provider (or subpart) who has been assigned an NPI must use the NPI to identify themselves in HIPAA standard transactions. If you need to identify a corporation or individual “as a taxpayer” with a different ID than the TIN, you can do so (for example, an SSN or an EIN). This exception does not apply to billing service providers or consumers of the remittance advice. An NPI must also be used to identify insured health care professionals “as providers” in some instances.

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