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JUNE 2008 V o l ume 5 , I ssue 3 Aetna OfficeLink Updates ™ Northeast Region Inside This Issue OfficeWise . . . . . . . . . . . . . . . It’s here! Access to Personal Health Records on NaviNet® 2-3 Policy and Practice Updates . . . . 4 Aetna’s Education Site for Health Care Professionals. . . . . . 5 Prescription Medications & Pharmacy Management . . . . . . . 6 Physician Focus. . . . . . . . . . . . . . . 7 Plan Facts and Features. . . . . . . . 8 Striving for Quality Excellence. . . . . . . . . . . . . . . . . . . 9 Northeast News. . . . . . . . . . 10-11 Options to reach us Go to www.aetna.com Select “for Health Care Professionals” n Select “Medical” n Select “Log In” or “Register Now!” n n Or call our Provider Service Center: n F  or indemnity and PPO-based benefits plans call 1-888-MDAetna (1-888-632-3862) 1-800-624-0756 for calls related to HMO-based benefits plans and WA Primary Choice plan n Providers who have registered for NaviNet can access Personal Health Record (PHR) information for their Aetna patients starting in late June. Please note that an Aetna member must first give their permission for their physician to view the PHR through NaviNet. Initially, only physicians whom the member designates will be able to access the PHR. Benefits of accessing a PHR Aetna’s PHR provides a comprehensive view of a patient’s health care treatment and health history. It contains up to 24 How to view a PHR months of health information derived There are two ways you can access a PHR: from medical claims, pharmacy claims, laboratory results and self-reported n  nce logged in to NaviNet, click on O information that patients can share with “Aetna Health Plan” from the “Health their doctors. Plans” list on the left. Then, to search for your patients’ PHR information, By accessing this information, physicians select the “View Personal Health can see which prescriptions were filled Records” button on Aetna’s Plan and when, whether diagnostic studies Central page. Once there, you can enter were performed and which specialists a search criteria to narrow your search by patient may have seen. We encourage you patient. Or, to ask your Aetna patients to authorize you for online access to their PHR. n  While performing an eligibility To learn more transaction, if a PHR was made If you have questions, contact NaviNet available to the requesting provider for Customer Care at 1-888-482-8057. Or, viewing, an “alert” will appear in the send an email by selecting “Contact Us” eligibility response. from the “Customer Service” section at the top of the screen. Take our Toolkit survey – we’ll enter you in gift card drawing We need your help. Let us know if the Health Care Professional Toolkit, our online provider manual, meets your needs. Please take a minute to tell us if the toolkit makes it easier for you to work with us by completing our brief online survey at https://navinet.navimedix. com/Main.asp. Once logged in, select 23.22.807.1-NE (6/08) “Aetna Support Center” then “Doing Business with Aetna” and “Health Care Professional Toolkit.” The survey is available from June 4 through August 29. Your completed survey automatically enters you in our drawing to win one of three $50 American Express gift cards. We will notify winners in September. OfficeWise Go totally electronic: Send us your COB claims Stop submitting coordination of benefits (COB) claims on paper. Start sending them to us electronically. When you submit COB claims electronically, you can edit them and monitor their status online. You can also: n n n necessary COB data. However, if your billing system can’t send this data electronically, we have other resources to help you. n R  eceive quicker payments than through the mail. S  pend less time and money on administrative tasks. n K  now your claims transactions are secure and protected. n Additional resources to help you We can accept your COB (secondary) claims electronically, provided your practice management system can create or forward claims that include L  og in to our secure provider website and use our free “Claims Submission” feature. Claims submission materials are available in the “Aetna User Guides” section of NaviNet Customer Care. C  ontact your claims vendor or clearinghouse for assistance. S  ubmit claims directly to us at no cost via Aetna EDI ConnectSM (www.aetnaedi.com). This option is best for technically savvy submitters. Why not go totally electronic today? eEOB tool offers many benefits The electronic Explanation of Benefits (eEOB) tool on our secure provider website is now accessible to all provider offices. With this tool, you can turn off paper EOBs and enroll in electronic funds transfer (EFT), a fast, secure method of receiving claims payments. You can also take advantage of the many eEOB features listed below. Advantages of eEOB Start enjoying the benefits of using this time- and money-saving tool. You can: n n n n n 2 A  ccess your EOBs 24/7 R  eceive reimbursement up to one week faster by using EFT instead of getting your checks through the mail O  rganize records electronically E  liminate administrative costs associated with retrieving paper EOB files S  earch by claim, patient, payment or provider Aetna OfficeLink Updates n A  ccess claims detail pages and statements for finalized claims n R  eview real-time claims status n S  ubmit claims reconsiderations online Win a gift certificate What’s more, by suppressing paper EOBs or enrolling in EFT, you’ll have an opportunity to win a $2,500 Dell™ gift certificate. To access the tool on our secure provider website, select “Claim EOB Tool” from the “Aetna Plan Central” home page. Then select “Paper Shut Off” or “EFT Enrollment,” respectively, and the online forms will appear. If you don’t see “Claim EOB Tool” on the home page, contact your office’s NaviNet security officer to obtain access. Facilities: Open the door to electronic communications Are you a participating facility or hospital that wants to say “goodbye” to paper correspondence and clutter? If so, go to https://aetna. providerpreference.com/facilities. php and register to receive electronic communications from us. Receiving electronic communications means you can quickly and efficiently have critical information from us at your fingertips – and at your convenience. Don’t wait for paper correspondence…sign up today. OfficeWise What’s new on our secure provider website We’re continually refreshing our secure provider website to give you access to the latest tools and resources for doing business with us. Content updates include: Clinical Resources n n Doing Business with Aetna n n n n A  dded Aetna Benefits Products Addendum – new products as of 2008 A  dded Aetna at a Glance – New Provider Welcome Kits under Mailings R  eplaced Medicare “Zero” Copayments for Preventive Services and updated Medicare Vaccine Information for all Aetna Medicare Advantage Plans A  dded new patient safety flyer, Making health care safer for everyone, to Behavioral Health page Claims n U  pdated Preventive Services Guidelines page U  pdated Clinical Practice Guideline for Antidepressant Prescribing Guide for Use in Primary Care Forms Library n n U  pdated charting aids for Medical History, Physical Examination, Patient Progress Notes, Diabetic Foot Health Screen and Adult Health Maintenance U  pdated ERA/EFT Enrollment Packet Education n P  lease see the feature article in this issue for recent updates to our Education Site for Health Care Professionals U  pdated Aetna Enhanced Grouper Information for 2008 Get drug safety alerts online Physicians can now receive important, time-urgent drug safety alerts online instead of through the mail. The Health Care Notification Network (HCNN) is free to physicians and includes no advertisements or marketing materials. Once you sign up, HCNN will email you alerts about significant drug-label changes, warnings and recalls. For more information or to enroll, go to www.hcnn.net Members may consult you after using our hospital comparison tool The Aetna Navigator® Hospital Comparison Tool will be available to you through our secure provider website in early June. This interactive tool enables users to compare hospitals on certain procedures and diagnoses. It is already available to Aetna members through Aetna Navigator, our secure member website. We encourage members to review our health-related information, tools and resources, and share their findings with their practitioners. After using this tool, your Aetna patients may want to discuss options for hospital referrals for specific procedures. View tool on secure website Once you are on “Aetna Plan Central,” select “Clinical Resources” under “Aetna Support Center” and link directly to the Hospital Comparison Tool. You can search more than 150 diagnoses and procedures to compare over 6,000 hospitals nationwide. Users can print a report that compares hospitals on four inpatient measures: n T  he number of patients treated per year For the most up-to-date information on the Aetna Medicare Preferred Drug List, go to: http://www.aetna.com/members/individuals/medicare/member_ assistance/changes.html M  ortality rates n We update the Aetna Medicare Preferred Drug List, also known as our formulary, from time to time during the year. As a result, it’s important for prescribing physicians to reference the Medicare Preferred Drug List to confirm which prescription drugs are covered under our Medicare plans. C  omplication rates n Keep track of Medicare formulary changes n A  verage lengths of stay The report also includes results from The Leapfrog Group Hospital Quality and Safety Survey and data published by the Centers for Medicare & Medicaid Services. We contract with WebMD Health Services to make the Hospital Comparison Tool available. JUNE 2008 3 Policy and Practice Updates Clinical, payment and coding policy changes As part of our ongoing policy review process, we regularly adjust our clinical, payment and coding policy positions. In developing our policies, we may consult with external professional organizations, medical societies and the independent Physician Advisory Board, which provides advice to us on issues of importance to physicians. The accompanying chart outlines coding and policy changes: codes impacted Procedure What’s Changed Implementation Date 706.0 and 706.1 Chemical peels, epidermal We are changing diagnosis codes 706.0 and 706.1 from covered to not covered in CPB 251 for chemical peels and epidermal. September 1, 2008 Oncotype DX® test requires pre-claim review Artificial disc surgeries need precertification For an Oncotype DX test to be covered, you must follow a pre-claim review process. This will help determine if the patient meets the clinical criteria outlined in our Clinical Policy Bulletin (CPB) #0352. Aetna’s Precertification List now includes a requirement for all artificial disc surgeries. This provision is in keeping with our policy that all inpatient admissions be precertified. As a reminder, please discuss with your patient the potential test results prior to testing and agree that the results will be used to guide therapy. To start the pre-claim review process, call Genomic Health at 1-866-662-6897. Genomic Health will send you a form to complete and fax back to them. The patient must meet all conditions listed on the form to be approved for the test, as stated in our CPB. Precertification approvals are valid for six months from the date of issue, unless stated otherwise. Precertification requirements apply to all Aetna plans, except Traditional Choice® and the Aetna Medicare OpenSM Plan, our Medicare Private Fee-for-Service plan. You can find the necessary criteria for coverage in Clinical Policy Bulletin #0352 at www.aetna.com. To view the precertification list, go to www.aetna.com, select “for Health Care Professionals” then “Medical.” How we’re reducing your volume of mail The next time you get mail from us, it might look a little different. And, you may have less mail to open. Maybe you’ve already noticed the change. We’re combining all your provider claims checks, letters and Explanation of Benefits (EOB) statements, where appropriate, so your office receives fewer packages from us. And, in response to your requests, we’ve reformatted some of our provider EOBs 4 Aetna OfficeLink Updates and claims letters to make them easier to read. In this order, you’ll find: n These changes began in mid-May, and are being implemented for all providers by the end of June. Convenient information For easier viewing of the contents, we’re grouping similar items together and putting the most important materials on top. C  hecks and remittances n E  OBs n C  laims letters If you have questions, email us by clicking the “Contact Aetna” icon on our secure provider website. Aetna’s Education Site for Health Care Professionals Learning Opportunities From Aetna....Developed With You In Mind Free webinars are now available More than 85 percent of health care professionals responding to our last annual survey said it would be valuable if we offered virtual training seminars. Busy health care professionals often can’t get away to an in-person educational seminar, which is why we’ve implemented a series of ongoing virtual seminars – “webinars.” We use your feedback to design our learning opportunities for health care professionals. Thanks to a dedicated group of volunteer educators in several practices and facilities around the country, we successfully piloted and introduced a series of new webinars. We also offer select recorded webinars on our Education Site. n -  his 30-minute recorded webinar T offers information on handling coding practices. You’ll learn tools and tips for accurate and appropriate coding practices with us. A  etna In-Service Updates (Office A webinar is a virtual educational seminar offered through the Internet via your personal computer and phone line. You can attend our live or recorded webinars free of charge at a time that’s convenient for you from your own office. administrative updates on key information available via a live webinar.) n Live and recorded webinars your peers helped design include: How to enroll in a live or recorded webinar -  his 1-hour webinar helps you T understand our consumer-driven benefits plans and how to administer them using our secure provider website, supported by NaviNet. The webinar also focuses on specifics about our coding policies and procedures. New online course offerings Continuing Education Recorded Events Quality Interactions® for New Jersey physicians (6 CME credits) Coding Tool Training recorded webinar Quality Interactions Refresher Course (Adolescent Health Case) Office Administration Tour Aetna’s Secure Provider Website via NaviNet What is a webinar? A  etna Coding Tool Training In addition to online courses, we offer Aetna in-service, face-to-face sessions and webinars. For upcoming events, see our online calendar on the Education Site by visiting our secure provider website and clicking on the Education link. n n This group gives us feedback on our educational offerings and helps us create new, relevant courses. If you would like to help us continue to shape education with you in mind, email us with the items below to AetnaEducationSite@aetna.com: n n n Pri-Med is a national network of continuing medical education programs that offers practicing clinicians world-class education where you live and work. If you’ve attended these events, you pay have noticed Aetna’s participation, supplying attendees with free patient education materials that support the doctor-patient relationship. T  o view a recorded webinar event – search for titles via the Recorded Events course catalog Interested in joining our panel of educators? n Supporting the doctor-patient relationship To  enroll in a “live” webinar event – click on the calendar to see upcoming events. n n n Aetna at Pri-Med Log in to our secure provider  website and select Education. P  ractice name A  ttention Street address C  ity, state and zip Phone number E  mail address We’ve handed out materials on subjects ranging from diabetes and asthma to cardiovascular health – information that often reinforces topics covered in the Pri-Med curriculum. conference, the highest steppers won prizes in our “Step It Up” contest. Our physician winner walked off with a fleece jacket after totaling over 22,000 steps. Getting active in Houston For upcoming Pri-Med events in your area, see the calendar on the home page of our Education Site. We also like to add an element of fun. Recently, at the Houston Pri-Med, we got attendees up and walking – literally – by giving out pedometers. At the end of the Visit our booth at upcoming Pri-Meds JUNE 2008 5 Prescription Medications & Pharmacy Management Updates to the Aetna Commercial Preferred Drug List We periodically review the Aetna Preferred Drug List (formulary) to make sure it meets established criteria for safety, effectiveness and overall value. Recent changes and updates to our formulary are listed below. To view the complete Aetna Preferred Drug List, go to www.aetna.com/formulary. Drug COverage update precertification step-therapy quantity limits FORMULARY ADDITIONS Renvela Tab® (sevelamer carbonate) Preferred (P) Tekturna HCT® (aliskerin hydrochlorothiazide) P X Alendronate P X Olux-Olux E® Complete Pack (clobetasol prop foam and clobetasol emul foam pack) P Humira® Kit 20 mg/0.4 ml (adalimumab inj kite 20 mg/0.4 ml) Preferred Pharmacy Managed Self-Injectable (P-PMSI) FORMULARY Removals Fosamax® (alendronate) Formulary Excluded (FE) X NEW DRUGS – Nonpreferred (NP) or FE Ibudone™ (hydrocodone/ibuprofen) FE Pad® NP Lidamantle HC acetate pad 2-2%) (lidocaine/hydrocortisone Intelence™(etravirine) NP Allegra® ODT (fexofenadine) FE X Luvox® CR (fluvoxamine maleate SR) X X FE Simcor® (niacin/simvastatin) FE Evamist™ (estradiol transdermal spray) FE Lamisil® granules (terbinafine oral granules) FE X NP Fenoglide™ (fenofibrate) X X FE Dazidox™ (oxycodone hcl) X X X Medications may be covered at a higher copayment or removed from our formulary after appropriate notification to providers and affected members. As brand-name medications lose their patents and generic versions become available, the brand-name medication may be covered at a higher copayment and/or may be added to the Formulary Exclusions List for commercial closed formulary plans. The Aetna Preferred Drug List may change because the Food and Drug Administration approves many new medications throughout the year, or medications may be withdrawn from the market or become available without a prescription. When an over-the-counter equivalent becomes available, the prescription medication may no longer be covered under many of Aetna’s commercial pharmacy benefits plans. California HMO members receiving coverage for medications added to the Formulary Exclusions, Precertification or Step-Therapy lists will continue to have those medications covered, as long as the treating physician continues prescribing them, provided that the drug is considered safe and effective for treating the member’s medical condition. Texas members: if currently covered, full-risk members will continue to have medications that are removed from the Preferred Drug List covered at the same benefit level until their plan’s renewal date. The term “precertification” does not mean a reliable representation of payment of care or services to fully insured HMO and PPO members. Some programs, such as step-therapy, precertification and quantity limits are not available in all service areas. Precertification programs do not apply in Indiana. Step-therapy does not apply to fully insured members in Indiana and New Jersey. Members should refer to their plan documents or call the Member Services number on their ID card. New billing requirement for Ceftriaxone Beginning September 1, 2008, Aetna will no longer routinely pay Ceftriaxone claims that fall above these dosing levels: n 6 A  dults: Total daily dose should not exceed 4 grams (16 units). Daily dose is usually 1 to 2 grams given once a day (or in equally divided doses twice a day), depending on the type and severity of infection. Aetna OfficeLink Updates n C  hildren (age 12 and under): Total daily dose should not exceed 2 grams (8 units). Total daily dose is usually 50 to 75 mg/kg given once a day (or in equally divided doses twice a day). You should bill for Ceftriaxone using code J0696 with a unit of 1 for each 250 mg of Ceftriaxone administered. This billing change results from a claims review where we found some instances of incorrect billing for single doses that are substantially above levels recommended by the FDA-approved product labeling. These amounts are recommended by the United States Pharmacopoeia Dispensing Information (USPDI) and the American Society of Health-System Pharmacists (ASHP) (drug information). Physician Focus™ 2008 and Beyond: Aetna’s Commitment to Physician Relations A message from Troyen A. Brennan, M.D., Aetna Chief Medical Officer The Physicians Settlement Agreement with Aetna ends this June. But the agreement’s formal expiration has no impact on the way we will continue working with physicians. All of the changes Aetna made as part of the settlement agreement are embedded in our business model. They are in our DNA and serve as a foundation for what we anticipate will be future collaborations with the medical community to make health care safer and more effective. We have worked hard to strengthen physician relations. Over the last few years, we have established a level of trust with health care professionals and expect to build on that in the years ahead. We want to continue to be a high-integrity business partner with the medical community. We also understand that we must demonstrate that commitment not only through words, but actions. With the settlement agreement about to end, Aetna proactively reached out to state medical societies to share our commitment to continuing virtually all of the provisions contained in the settlement. The only provisions we are not continuing are a few administrative details that have outlived their usefulness. For example, the annual compliance report has become obsolete, since we now address and resolve issues face to face with the medical societies. We also have established Guiding Principles for Physician Relations that formally define Aetna’s genuine desire to building the best possible relationships with the medical community. The document identifies specific behaviors and business actions that govern Aetna in its interactions with health care professionals. It also outlines business practices we will maintain including simplified business transactions, increased transparency of policies and processes, and working with the medical community to encourage adherence to evidence-based guidelines in medicine. These Guiding Principles clearly demonstrate, in writing, that we are serious about making it even easier to do business with us and moving forward with the medical community with a shared focus – improving outcomes for patients. “ e want to continue to be W a high-integrity business partner with the medical community.” For a copy of Aetna’s Guiding Principles for Physician Relations, go to our public website at http://www.aetna.com/provider/medical/join_med/advantages_med/ advantage.html. Aetna also will continue the Physician Advisory Board, and will consult with the Physicians Advocacy Institute, the organization funded by the medical societies to ensure that payers are behaving reasonably. Sincerely, Troyen A. Brennan, M.D. Senior Vice President and Chief Medical Officer JUNE 2008 7 Plan Facts and Features Benefits of immunization registries Plain language materials help members with asthma Immunization registries are confidential, computerized databases used to maintain immunization records on a statewide basis. Aetna last year began a study to see if clearer, simpler health information could help members with asthma understand and better manage their disease. Preliminary results indicate that easier-to-read health information can improve patients’ knowledge about asthma and how to control it. How we conducted the study Members were placed in either a control or outreach group. We then measured each group’s baseline knowledge of asthma. The outreach group received information about asthma written in updated “plain language” while the control group received standard materials. The materials written in “plain language” have shorter sentences and words that are familiar to people without medical training. Preliminary results and next steps At one-month follow-up, members who received the “plain language” asthma materials scored higher on the knowledge survey than those in the control group. Follow-up studies will determine if members retain long term the information they learned about asthma care and control. We’ll also look at whether improved knowledge results in better medication compliance and health outcomes. Participating in an immunization registry can help your office by: n n n An award-winning study The Institute for Healthcare Advancement (IHA) recognized our efforts to promote health literacy and better health outcomes. The asthma health literacy study was selected as the winner in the Research Category in the IHA’s Health Literacy Awards competition. n n n We’ve simplified our Aexcel® We continue to improve and strengthen our Aexcel designation process to make it more understandable for members and physicians. Beginning this year, physicians in Aexcel specialties will be evaluated for efficiency using one methodology – the Symmetry Episode Treatment Groups®. We previously used two methodologies when evaluating a physician’s efficiency of care. n n 8 F  or 2008, we will exclusively use the Symmetry methodology in markets that will introduce Aexcel in 2009 and in existing markets whose two-year Aexcel re-designation review occurs in 2008. F  or 2009, this change will apply to markets introducing Aexcel in 2010 and to the remaining existing markets whose Aexcel re-designation review occurs in 2009. Aetna OfficeLink Updates efficiency methodology Why we use one methodology Our experience shows that Symmetry produces more year-to-year consistency in determining which physicians are efficient, compared to using two methodologies. In addition, using one methodology simplifies review of performance measurement results for physicians and streamlines our evaluation process. Symmetry is also integrated with our other provider performance initiatives, such as Provider Quality Performance ProgramSM (formally known as Pay-for-Performance). This helps ensure we are using a standard, consistent methodology when evaluating and measuring provider performance across all programs. n P  roviding a reliable immunization history about your patients, helping to eliminate duplicate immunizations if patients previously saw other providers. I  mproving office efficiency by consolidating immunization information in one source. S  implifying completing the proof-ofimmunization paperwork for your patients’ school, camp and daycare admission requirements. E  nhancing quality of care by generating appointment reminders for immunizations that are due or overdue. A  utomatically recording vaccine manufacturer and lot number for each patient, which can help identify patients for revaccination in cases of recalled vaccine lots. R  educing the need for your office to obtain documentation during HEDIS data collection. P  roviding safe storage of data in case of an office disaster or lost records. Go to www.cdc.gov/vaccines/programs/ iis/default.htm to locate your state’s immunization registry and for information on how you can participate. Aetna’s depression screening program The Aetna Depression Management Program provides resources for primary care physicians (PCPs) to help diagnose and treat patients with depression. We also offer PCP offices participating in this program additional compensation for screening Aetna members for depression. To learn more or to participate, call 1-888-812-3862 or email us at depression@aetna.com. You can go to www.aetnadepressionmanagement.com to register for the program, tour program highlights and find printable office tools. Striving for Quality Excellence Keeping you informed: NCQA-required notification The National Committee for Quality Assurance (NCQA) requires health plans to inform physicians of certain policies, standards and programs annually, including: n n n Members’ rights and responsibilities C  ase management and disease management programs and how members and providers can access them Information on advance directives You’ll find information on these and other topics in our Health Care Professional Toolkit, available online through our secure provider website. Medical practices without Internet access can request a paper copy by calling our Provider Service Center. Advance directives QI program information The Centers for Medicare & Medicaid Services requires that information on whether a member has prepared an advance directive be documented in your Medicare patients’ charts. Aetna Participating Practitioner Medical Record Criteria require that documentation about advance directives (whether executed or not) is in a prominent place in the patient’s record (except for patients under age 18). If you want information on our Quality Improvement (QI) program goals, call our Provider Service Center. These goals include: Advance directive forms for specific states are posted on www.aetnacompassionatecare.com. If the state you practice in is not listed, you or your patients can visit www.uslivingwillregistry.com/forms. shtm for an advance directive form or for additional information. n n n M  easuring, monitoring and achieving optimum performance of clinical and service quality. I  mplementing a program that is responsive to members’ health care needs. Complying with requirements of benefits plans, plan sponsors, federal and state regulators, and appropriate accrediting bodies. New HEDIS® documentation requirements for DTaP Coverage determinations and utilization management HEDIS 2009 requires that for immunizations given in 2006, 2007 and 2008, health plans must now confirm in the medical record that members received the acellular pertussis (aP) vaccination, in addition to the diphtheria and tetanus (DT) vaccinations. Aetna uses evidence-based clinical guidelines from nationally recognized authorities to guide utilization management (UM) decisions. To help us with HEDIS reporting, we ask that the member’s medical record clearly indicate that the DTaP vaccine was given and the date. Charting aids that display multiple vaccines together, such as DTaP/DTP/DT, are not acceptable. A Pediatric Vaccine Record form that meets HEDIS documentation standards is posted on our secure provider website. If your patients got a DTaP vaccine in 2006 or 2007 and your office used a charting aid that grouped DTaP, DTP and DT together, please circle DTaP so we know that vaccine was administered. Accessing the vaccine record form To access the Pediatric Vaccine Record form from our secure provider website, select “Aetna Support Center,” “Forms Library” and “Pediatric Vaccine Record” under “Member Health Information Forms/Charting Aids.” HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Specifically, we review any request for coverage to determine if the member is eligible for benefits, if the service requested is a covered benefit under the member’s plan and if the service is delivered consistent with established guidelines. If a coverage request is denied, the member (or a physician acting on the member’s behalf) may appeal this decision through our complaint and appeal process. Staff conducting UM activities assist members in accessing services covered under their plans. We do not reward physicians or individuals who conduct utilization review for creating barriers to care or for issuing denials of coverage. You can find more about our utilization review policies on our website. Aetna OfficeLink Updates JUNE 2008 9 Northeast News Online pricing information available for additional health care specialties Along with pricing information for participating physicians, beginning in June our price transparency tool will include pricing information for these specialists: n Physical therapists n Occupational therapists n Speech therapists n Speech pathologists n Audiologists n Chiropractors n Podiatrists n Members in areas where this tool is available can view rates for office visits with these professionals. Depending on the specialty, rate information may also be available for diagnostic tests, as well as for major, minor and other procedures. Optometrists The unit price transparency tool is available to members through our secure member website and helps them make more informed, cost-effective decisions about their health care. Consultative services available through Vital Decisions1 We are pleased to support physicians with access to a new service to help patients with chronic and complex illnesses, or end-oflife decisions. Vital Decisions is a health care counseling service that helps patients who are facing difficult medical situations make well-informed health care choices. Helping you help your patients For physicians striving to help their patients create an effective advance care plan, it can be helpful to have a health care/bioethics counselor who can assist in setting realistic care goals. The Vital Decisions service includes ethicists, nurses, physicians, social workers and other professionals with extensive experience in bioethics/health care consultation. The telephone-based service provides information and tools to help the patient and his/her family: n U  nderstand the patient’s medical situation and prognosis. 10 Aetna OfficeLink Updates n n n C  larify medical, ethical and legal issues relating to treatment and the setting of realistic care goals. Here’s how to learn more E  xplore options to help the responsible parties arrive at the best plan of care for the patient. Visit the Vital Decisions website at www.vitaldecisions.net or contact them at 973-379-0079. To refer a member for this service, complete a Counseling Request Form on the website. C  ustomize care by matching the medical choices to the individual’s personal goals, preferences and values. You may also contact Aetna Medical Director Ira Klein, M.D., M.B.A., F.A.C.P, at 908-369-0818 with questions. The service is a fully covered member benefit, with the Vital Decisions counselor remaining a 24/7 resource for the patient throughout the entirety of their illness. While referrals can be requested by either a physician, member or a member’s representative, the Vital Decisions counselor will always contact the attending physician about any impending consult. Recommendations or guidance offered during the consultation are advisory, with the patient’s physician directing the course of care. Vital Decisions is a contracted entity, and is not otherwise affiliated with Aetna. Aetna is not responsible for any advice or actions taken by Vital Decisions. 1 Don’t just think outside the box. Think outside the mailbox. Close the mailbox and open your inbox. Get information electronically from Aetna through email instead of in a paper format in your mailbox. Visit https://aetna.providerpreference.com Sign up today for our electronic correspondence option. JUNE 2008 11 PRSRT STD U.S. POSTAGE PAID PERMIT NO. 12 ENFIELD, CT CPE RS51 151 Farmington Ave. Hartford, CT 06156 Contact us at: OfficeLinkUpdates@aetna.com Please route this publication to: q Office Manager q Business Staff q Front Desk Staff q Medical Records/Medical Assistants q Primary Care Physicians q Specialists q Physician Assistants/Clinical Nurse Specialists q Nurses q Referral and Precertification Stafftaff Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefits coverage include Aetna Health Inc., Aetna Health of California Inc., Aetna Life Insurance Company and Corporate Health Insurance Company and Strategic Resource Company. Register for NaviNet website to get clinical alerts Our improved secure provider website via NaviNet has many new features and enhancements, including important “Care Considerations” for your Aetna patients. However, you can’t review online Care Considerations if you aren’t registered with NaviNet. Supporting patient care Care Considerations are clinical alerts based on a member’s claims history. MedQuery®, administered by our subsidiary ActiveHealth Management, compares a member’s pharmacy, laboratory and medical claims against clinical algorithms derived from published medical evidence and guidelines recommended by professional organizations. Care Considerations identify potential gaps in care and bring these to the attention of the treating physician. Most Care Considerations pertain to disease and drug interactions; tests, medications or monitoring patient needs based on an existing health condition; and preventive care or screenings that are overdue. Physicians can use this information to adjust a treatment plan or suggest the patient schedule a recommended test or screening. Receiving Care Considerations Once you are registered, Care Considerations will display in your NaviNet Action Items and as an “alert” within an electronic eligibility response. Your office may want to establish a workflow to review and respond to online Care Considerations. To register for NaviNet, go to www.aetna.com. Select “for Health Care Professionals,” “Medical,” then “Register Now!” from the “Provider Secure Website” box on the right. The information and/or programs described in this newsletter may not necessarily apply to all services in this region. Please contact your Aetna network representative to find out what is available in your local network. Application of copayments and/or coinsurance may vary by plan design. This newsletter is provided solely for your information and is not intended as legal advice. If you have any questions concerning the application or interpretation of any law mentioned in this newsletter, please contact your attorney. 23.22.807.1-NE (6/08) ©2008 Aetna Inc.