NOTICE OF CLAIM PROCESS
(This is not a solicitation from a lawyer. You are not being sued.)
If You Are a Health Care Provider That Rendered Services to an Aetna Member Between
October 1, 2003 and April 1, 2005, and Billed Aetna for Those Services Under CPT 77336
(“Continuing Medical Physics Consultation”), But Were Denied Reimbursement by Aetna and
Not Otherwise Paid, Then You Are Entitled to Resubmit Those Claims in This Claim Process to
Seek a Complete Reimbursement for Those Claims.
PLEASE READ THIS NOTICE CAREFULLY.
IT CONTAINS IMPORTANT INFORMATION REGARDING YOUR RIGHTS.
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In May 2006, Bardmoor Cancer Center, Dr. Alan Tralins, and Dr. Kevin Tralins (“Bardmoor”) brought a
claim in arbitration against Aetna in connection with Aetna’s general policy to deny separate
reimbursement for services billed under CPT 77336 as incidental to the primary course of treatment
(“Disputed Policy”) between October 1, 2003 and April 1, 2005.
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In June 2007, Bardmoor and Aetna settled the arbitration. As part of the Settlement Agreement
(“Agreement”), and because Aetna values its relationships with all health care providers, Aetna agreed
to create a Claim Process in which any Provider who previously submitted a claim to Aetna seeking
reimbursement for services rendered under CPT 77336 between October 1, 2003 and April 1, 2005, but
which was denied reimbursement by Aetna pursuant to the Disputed Policy and not otherwise paid,
would have the opportunity to resubmit those claims for full payment, as described below.
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For all valid claims submitted, Aetna has agreed to pay 100% of the amount that the Provider would
have been paid, calculated according to Aetna’s fee schedule and/or reimbursement methodology
applicable to the Provider at the time that the CPT 77336 claim was originally denied by Aetna. The
amount of payment will not include any interest or penalties and Aetna has the right to deny resubmitted
claims for any valid normal business reason unrelated to the Disputed Policy (e.g., claim was already
paid, member ineligibility). Also, as described below, any resubmitted claim will be reprocessed under
Aetna’s current reimbursement policy for CPT 77336 (i.e., reimbursement of such services once per day
and up to twice per week per member).
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As part of the Settlement, Hanzman, Criden & Love, P.A., Bardmoor’s legal counsel in the arbitration,
has agreed, AT NO COST TO THE PROVIDER, to oversee the entire Claim Process, to answer
Provider’s questions about the Claim Process, and to generally assist providers in completing the Claim
Form. To contact Hanzman, Criden & Love, P.A., call toll-free at 1-877-357-9001 or send an e-mail
to klove@hanzmancriden.com.
*
Claim Forms Must Be Mailed To Aetna And Postmarked On Or Before January 17, 2008.
However, the Faster You File Your Claim, the Faster Aetna Will Process Your Claim.
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GENERAL INFORMATION
1. Why Did I Get this Notice?
You received this Notice because you may have submitted claims to Aetna for services billed under CPT 77336
that were performed between October 1, 2003 and April 1, 2005, but which claims were denied because of Aetna’s
Disputed Policy. If that is the case, you are eligible to file a claim in the Claim Process and receive 100% of what
you would have received had Aetna not previously denied the claim due to the Disputed Policy.
2. What Is CPT 77336?
The description of “CPT 77336” in the CPT manual is “continuing medical physics consultation, including
assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment
documentation in support of the radiation oncologist, reported per week of therapy.”
3. What Is the Disputed Policy?
During the period between October 1, 2003 and April 1, 2005, it was Aetna’s general policy to deny separate
reimbursement for services billed under CPT 77336 on the basis that these services were incidental to the primary
course of treatment. Only claims that originally were denied under the Disputed Policy and not otherwise paid are
eligible for submission under the Settlement.
4. Aetna Is Currently Reimbursing Me for Services Under CPT 77336; Do I Need to File a Claim Form?
Yes, if you would like to seek reimbursement for CPT 77336 claims for services performed between October 1,
2003 and April 1, 2005 that were not otherwise paid. Beginning on April 1, 2005, Aetna changed the Disputed
Policy and began reimbursing for CPT 77336 services as a separate code. Prior to October 1, 2003, Aetna also
reimbursed CPT 77336 as a separate code. Until now, Aetna would not generally pay providers for CPT 77336
during the period between October 1, 2003 and April 1, 2005 because of the Disputed Policy. Aetna is now
providing this Claim Process to allow Providers to obtain reimbursement for CPT 77336 services rendered for the
time period between October 1, 2003 and April 1, 2005.
THE CLAIM PROCESS
5. Who Is Eligible to File a Claim Form?
Any Provider (participating or non-participating) who previously submitted a claim to Aetna seeking
reimbursement for services performed under CPT 77336 between October 1, 2003 and April 1, 2005, and was denied
reimbursement by Aetna pursuant to the Disputed Policy, and not otherwise paid, may resubmit those claims for
payment in this Claim Process.
6. Can I Submit Claims Even If I Didn’t Appeal Aetna’s Original Denial?
Yes, you can submit claims whether or not you appealed the original denial by Aetna. Even if you appealed and
lost, you can still submit those claims in this Claim Process.
7. Can I Submit CPT 77336 Claims If I Didn’t Originally Submit Them to Aetna?
No. Only CPT 77336 claims that were originally submitted to Aetna and were denied because of the Disputed
Policy and not otherwise paid may be resubmitted in this Claim Process.
8. Can I Submit CPT 77336 Claims That Were Denied Solely for a Reason Other Than for the Disputed
Policy?
No, if your CPT 77336 claim was denied solely for a reason other than the Disputed Policy (e.g., the claim had
already been paid; the member was ineligible), Aetna will not review that decision in this Claim Process. It was,
however, Aetna’s general policy to deny CPT 77336 claims during the period between October 1, 2003 and April 1,
2005, because of the Disputed Policy. If Aetna denied the CPT 77336 claim because of the Disputed Policy and
because of another reason, then you have the right to resubmit the claim in this Claim Process. As explained below,
however, Aetna may have the right to again deny the claim for those other reasons.
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9. I’m with a Medical Group; How Do I File a Claim?
For purposes of this Claim Process, any Provider may file a Claim Form, whether that Provider is an individual
physician, physician group, facility, or other health care provider. Thus, medical groups that include more than one
provider may file one Claim Form for their respective medical group, provided that is how the claims were originally
submitted to Aetna.
10. How Do I File a Claim Form?
The Claim Form provides step-by-step instructions on how to complete the form and what other information
needs to be submitted with the Claim Form (see discussion of “Supporting Documentation” below). The Claim
Form also includes the address to which the completed Claim Form and Supporting Information must be sent. The
particular address for you to mail your claim submission will depend on where you are located. If the information
you are sending is not voluminous, then you will have the option of faxing it.
11. What Is the Deadline for Filing the Claim Form?
The Claim Form and Supporting Documentation must be returned to Aetna. If sent by mail, the claim
submission must be postmarked on or before January 17, 2008. If you fax it, the claim submission must be faxed
on or before January 17, 2008. If your claim is untimely sent, then your claim will be denied.
12. Do I Need to Submit to Aetna Anything More Than the Claim Form?
Yes, you need to submit “Supporting Documentation” with the Claim Form, which is a minimal amount of
information. “Supporting Documentation” is defined as any of the following: (i) copies or reprints of a CMS 1500,
UB 92, or equivalent electronic submission originally submitted to Aetna; or (ii) copies of explanation of benefits
forms for claims originally submitted to Aetna; or (iii) a spreadsheet with the information requested in the Claim
Form; or (iv) other documents that include the information requested to be put into the spreadsheet in (iii) above.
You need only submit one form of documentation to support your claim.
13. What If I Don’t Have All of the Information You Are Requesting in the Claim Form?
You should try to provide as much information as is possible; but if you don’t have all of the information
requested, you should still submit your claim with the information that you do have. Aetna will use its best efforts to
reprocess all of the claims regardless of whether the Claim Form and Supporting Documentation includes all of the
information requested.
14. If I Submit Supporting Documentation for Several CPT 77336 Claims, Do I Still File Only One Claim
Form?
You need only file one Claim Form per submission no matter how many CPT 77336 claims you are including in
the submission. If you send in a Claim Form, and you later find more CPT 77336 claims you wish to submit for
reimbursement, then you need to file another Claim Form along with the additional claims.
15. If I Need Another Claim Form, How Do I Get Another One?
You can call 1-877-357-9001 to request another Claim Form.
16. If I Originally Submitted My Claims Electronically to Aetna, Do I Need to Print Out Each Claim and
Attach Them to the Claim Form?
No. You may provide the Supporting Documentation either in electronic or paper form, or both. For example, if
your original claim information is on your computer, you can download that information to a computer disk and
submit the disk with the Claim Form.
17. Will I Ever Need to Submit Clinical Information?
No. Under the Agreement, clinical information, chart notes or similar information is not required to be
submitted at any point during the Claim Process, except to the extent that you elect to provide this type of
information during an appeal of a claim denial.
18. Will the Information I Send Be Treated by Aetna as Confidential?
Yes. Aetna will treat all information submitted in the Claim Process as confidential in accordance with
applicable law (including HIPAA) and contractual obligations.
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19. How Much Will Aetna Pay Me?
For each claim paid through the Claim Process, Aetna has agreed to pay 100% of what would have been paid
under Aetna’s payment schedule or reimbursement methodology in effect for that Provider at the time the service
was performed. There will be no deduction for attorney’s fees or costs associated with the Claim Process. The
payment shall not include any interest or penalties. If your claim is approved, Aetna will pay you in the manner it
normally pays you in the ordinary course of business.
20. If I Don’t Want to Participate in this Claim Process, Do I Need to Do Anything?
You should participate in this Claim Process if you want to be reimbursed for the CPT 77336 services you
performed between October 1, 2003 and April 1, 2005 and that were not otherwise paid. However, if for some
reason you do not want to participate in the Claim Process, you do not have to exclude yourself. You can do
nothing. Only those Providers who file Claim Forms will be releasing Aetna from any and all claims in connection
with the Disputed Policy and the CPT 77336 claims. Similarly, because this is not a class action, there is no right to
object to any terms of the Agreement or Claim Process.
21. Who Is Paying for the Costs of the Claim Process?
Aetna is paying for all costs related to the Claim Process.
22. Who Do I Call If I Need Help to File My Claim Form or Have Questions about the Claim Process?
You can call Hanzman, Criden & Love at 1-877-357-9001 (toll-free) or e-mail the firm at
klove@hanzmancriden.com. These are the lawyers who brought the original lawsuit on behalf of Bardmoor and
helped create the Claim Process for all Providers. As part of the Agreement, Hanzman, Criden & Love has agreed to
assist any and all Providers in the Claim Process AT NO COST TO THE PROVIDER. This assistance may
include helping Providers: (i) understand how the Claim Process works; (ii) filling out the Claim Form correctly; (iii)
gathering Supporting Documentation; and (iv) appealing any adverse decisions during the Claim Process. Aetna has
agreed to pay Hanzman, Criden & Love its reasonable fees and costs for its work in connection with the Claim
Process. Any payment to Hanzman, Criden & Love shall not in any way decrease the amount of money that a
Provider receives from the Claim Process. If you use a lawyer or anyone else (other than Hanzman, Criden & Love)
to assist you in the Claim Process, however, you will be responsible for paying them.
23. If I Use Hanzman, Criden & Love to Help Me in Getting Together My Claim, Will They Be My
Lawyers?
No, Hanzman, Criden & Love has agreed to oversee and assist Providers in the Claim Process, but they will not
provide any legal advice to any Provider.
24. Can I Hire My Own Lawyers to Represent My Interests in the Claim Process?
Yes, you have the right to hire your own counsel if you wish for the Claim Process, but you will be responsible
for the payment of that representation. Similarly, although it is unnecessary, you can hire a company to assist you in
the filing of the Claim Form, but if you do, you are responsible for paying them for their services.
25. If I Have Questions, Who Should I Call?
Under the Agreement, Hanzman, Criden & Love has agreed to oversee the Claim Process and to confirm that all
parties are complying with the Agreement. Hanzman, Criden & Love’s contact information is provided below (see
question 31). If you have questions for Aetna regarding the Claim Process, Hanzman, Criden & Love will provide
you with the appropriate contact information.
AETNA’S REVIEW PROCESS
26. What Happens After I File the Claim Form?
If the Claim Form is timely sent, Aetna will first review the submission to make sure the Provider has properly
filled out the Claim Form and that the Supporting Documentation is in a form that permits Aetna to reprocess the
CPT 77336 claims. If Aetna finds that the Provider’s submission is deficient (e.g., a Claim Form has not been
signed, Supporting Documentation is not in a usable format), Aetna will notify the Provider within 30 days
explaining the process by which the Provider may correct the deficient submission. The Provider will have 30 days
after receipt of the notice from Aetna to correct the deficiencies and resubmit the submission. If Aetna still believes
that the submission is deficient after it has been resubmitted, then Aetna shall notify the Provider of its rights to
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appeal that decision in accordance with the Agreement. Hanzman, Criden & Love is available to assist the Provider
regarding any claim submission issues.
27. If My Claim Submission Is Not Deficient, When and How Will Aetna Pay Me?
If a Claim Form has been properly submitted to Aetna, Aetna is able to reprocess the CPT 77336 claims, and
there is no other reason to deny the CPT 77336 claims (see question 29), then Aetna will pay the Provider within 90
days from the date Aetna receives the Claim Form. The payment shall be made in the usual manner for that
Provider. Thus, if Aetna generally wires the payment to your bank account, then Aetna shall wire any payment due
under the Claim Process. If payment cannot be made in the usual manner for a Provider, then Aetna shall send a
check to that Provider at the address on the Claim Form within the 90-day time frame.
28. What If I Believe That Aetna’s Payment Amount Was Not Calculated Correctly?
Providers who receive payments from Aetna from this Claim Process will have 14 days after receipt of the
payment to object to the amount of payment if they believe it was calculated incorrectly under Aetna’s applicable fee
schedule or reimbursement methodology for that Provider. Providers, including both participating and nonparticipating Providers, shall not be permitted to challenge Aetna’s fee schedule or reimbursement methodology for
that Provider. Any Provider contending that Aetna did not calculate the payment correctly under Aetna’s fee
schedule for that Provider must include a copy of that Provider’s contracted fee schedule or other documentation
stating Aetna’s fee schedule or reimbursement rate for that Provider along with the objection. Hanzman, Criden &
Love is available to assist the Provider regarding any payment issues.
29. What Are the Reasons Aetna Can Deny My Claim?
Aetna has the right to deny any resubmitted claims for any valid normal business reason unrelated to the
Disputed Policy (e.g., claim was already paid, member ineligibility, exceeds the number of CPT 77336 claims that
may be submitted for a given week of service under Aetna’s current policy). Apart from certain exceptions, Aetna
can deny a resubmitted claim only if it previously denied the claim for that same reason when originally submitted.
For example, if Aetna denied an original claim because of the Disputed Policy and because it believed the claim had
already been paid, then Aetna would have the right to deny the resubmitted claim on the basis that the claim was
already paid. As explained below, a Provider will have the right to appeal that denial if it so wishes.
30. What Happens If Aetna Denies My Claim?
Within 90 days from the date Aetna receives a properly submitted Claim Form, Aetna will notify the Provider of
any denials. The denial notification shall be accompanied by an explanation of the reason for the denial as well as
the procedure to appeal the denial.
GETTING MORE INFORMATION
31. Where Do I Get More Information about the Claim Process?
You can call Hanzman, Criden & Love at 1-877-357-9001 (toll-free) or e-mail the firm at
klove@hanzmancriden.com. These are the lawyers who brought the original lawsuit on behalf of Bardmoor and
helped create the Claim Process. As part of the Agreement, Hanzman, Criden & Love has agreed to assist any
Provider in the Claim Process at no cost to the Provider. Aetna has agreed to pay Hanzman, Criden & Love its
reasonable fees and costs related to the Claim Process in addition to any amount of money that Providers will receive
in the Claim Process. If you would like to review the Settlement Agreement that controls all aspects of the Claim
Process, or if you have any questions regarding the Claim Process, you can contact Hanzman, Criden & Love (see
contact information immediately below).
Kevin B. Love
Hanzman, Criden & Love, P.A.
7301 S.W. 57th Court, Suite 515
South Miami, FL 33143
1-877-357-9001
klove@hanzmancriden.com
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Hanzman, Criden & Love, P.A.
7301 S.W. 57th Court
Suite 515
South Miami, FL 33143
IMPORTANT DOCUMENT
