1. AETNA BETTER HEALTH® OF NEBRASKA
2015 AAHAM CONFERENCE

2. Welcome and Introductions
Provider Relations
Jeff Nelson- Provider Relations 2

3. Our Core Values 3 Be accountable and honor commitments
Be passionate about the people we serve
Set high expectations,
be decisive and execute
Behave ethically and act with integrity
Listen to customers, prioritize and deliver value
Communicate with candor
Anticipate the future and make a difference
Trust and respect each other
Coach, mentor and continuously learn
Be open to all voices and ideas
Be courageous, try new things and innovate
Be collaborative, caring and optimistic 3

4. Our Members – The Center of What We Do
Operations & Enrollment
Member Services & Member Advocates
Quality Management
Provider Relations & Provider Network
Appeals & Grievances
Medical Management
Collaborative Services 4

5. Provider Relations can be reached at (888) 784-2693
Aetna Better Health of Nebraska has dedicated Provider Relations staff
Provider Relations staff will visit provider offices regularly throughout the year to ensure Aetna is meeting their needs and addressing concerns
Provider Relations will:
Provide education to provider offices on a variety of topics
Provide support on Medicaid policies and procedures
Provide contract clarification
Assist with demographic changes, terminations, and initiation of credentialing
Monitor compliance with applicable State and Federal agencies
Conduct annual Provider Satisfaction Survey
Conduct member complaint investigation
Maintain the provider directory
Be a point of contact for provider concerns
Provider Relations can be reached at (888) 5

6. Claims Inquiry/Claims Research (CICR)
Claims Inquiry/Claims Research (CICR) will:
Be the first point of contact for providers with any claims questions
Assist with claims questions, inquiries and reconsiderations
Review claims or remittance advice
Claims Inquiry/Claims Research can be reached at (888) 6

7. Member Services can be reached at (888) 784-2693
Member Services will:
Provide information on eligibility and benefits
Assist providers with non-compliant members and/or discharges
Assist members with available programs and resources
Assist member in finding providers
Assist members in filing grievances or appeals
Member Services can be reached at (888) 7

8. Member ID Cards
New ID cards were issued on 8/25/14. All CoventryCares members should have new Aetna Better Health of Nebraska ID cards.
If the member does not have his/her new ID card, you can obtain enrollment verification at
Aetna Better Health will use the existing Medicaid ID number issued by the State of Nebraska 8

9. Member Eligibility
Aetna Better Health of Nebraska member eligibility can be verified through
Provider portal ( or
Member Services (888)
NMES Line (402) or (800) 9

10. Prior Authorization
Please review the new authorization requirements that went into effect August 25, 2014
Request new prior authorizations
Online: CareWebQI , access through the provider portal
Phone: (888)
Fax: (844) 10

11. Claims Submission
NEW Aetna Better Health of Nebraska EDI payer ID: 42130
NEW claims mailing address:
Aetna Better Health of Nebraska P.O. Box Phoenix, AZ
All claims should be submitted on the most current claim forms 11

12. Claim Timely Filing
Timely filing for Aetna Better Health of Nebraska for initial claims submission follows your Coventry Health Care of Nebraska HMO contract
Providers will have 180 days from the date of an initial claim denial to submit corrected claims or requested information 12

13. Provider Website http://aetnabetterhealth.com/Nebraska
Our provider website contains resources to assist provider interactions with Aetna Better Health of Nebraska:
View and download our provider manual, communications and newsletters
Searchable provider directory
Reconsideration and appeal forms
Clinical practice guidelines
Member materials
Fraud & abuse information and reporting
Gateway to our secure provider web portal
Information on resubmission and provider appeals
Review the member and provider handbooks 13

14. Provider Portal
Please visit:
Providers will be able to
Search member eligibility and verify enrollment
Search and initiate authorizations (CareWebQI)
Search claims status
View claim detail, explanation of benefits and remittance advice
View provider lists and panel roster
Contact the health plan via secure messaging 14

15. Provider Portal http://aetnabetterhealth-nebraska.aetna.com
All providers must register for the provider web portal prior
Submit web portal e-registration forms online
See our provider web portal navigation guide to learn more about the provider web portal available on the provider website
Each TIN will have one account, with a primary representative
The primary representative can add authorized representatives within their office to their account
Contact Provider Relations for help registering 15

16. Electronic Tools Electronic claims submission Payor ID 42130
Less paperwork, less wasted time, and a more efficient office
Lower claims rejection rates
Faster claim delivery than by traditional mail – clean claims mean less money wasted for reprocessing
Faster claim payment to your office
Ability to easily identify and resubmit claims with missing or invalid data 16

17. Electronic Tools Electronic funds transfer (EFT)
- Electronic funds transfer (EFT) will be our standard payment method
for provider reimbursement as of August 1, 2014
Electronic remittance advice (ERA files)
- RAs will no longer be mailed to your office effective August 1, 2014, or
30 days after you sign up for EFT
Please work with your clearinghouse to ensure you can receive ERA & have the correct file paths
Enroll in EFT/ERA electronically by visiting our Secure Web Portal
Paper forms can be found on the provider website
Sign up for EFT/ERA Please contact Provider Relations at (888) or with questions or to check EFT enrollment status. 17

18. Claim Resubmissions & Reconsiderations
Resubmission claims may be sent electronically
Label all corrected claims as “Corrected Claim” on the claim form
Send all claim lines again, not just the line being corrected
Send paper reconsideration claims with attached documentation to:
Aetna Better Health of Nebraska Attn: Claims Resubmission/Reconsideration
P.O. Box Phoenix, AZ
Please use the Reconsideration Form found on the provider website 18

19. Appeals
Our provider appeals process is utilized to dispute an adverse action of a denial, reduction or termination of a requested service
Post-service appeals are initiated in writing by mail
The appeal must specifically state the factual and legal basis for the appeal and the relief requested
Documents to support the appeal should be provided, such as a copy of the claim, remittance advice, medical review sheet, medical records, correspondence, etc.
Appeals on issues other than claims denials, such as authorization denials, must be filed no later than 90 days after the date of the adverse action
Appeals are reviewed within 90 days
Once you receive a notice of resolution, this will conclude your appeal process 19

20. Grievances
A grievance is any written or verbal expression of dissatisfaction over a matter other than an action by a member or provider authorized in writing to act on the member's behalf.
Examples: Quality of care, quality of service, provider behavior, office environment, potential fraud and abuse
Grievance process
Acknowledged within 5 calendar days
Investigated by provider relations, quality management and/or by the State’s Ombudsman
May involve office site visits and assessments
Egregious grievances may warrant peer review and/or trigger an off-cycle credentialing review
Resolution and response to the member within 90 calendar days 20

21. Quality Programs EPSDT Monthly post card mailing & reminder calls
Well Woman
Monthly birthday card mailing
Case Management
Pediatric, adult, perinatal
Disease Management
Diabetes, congestive heart failure, asthma, COPD
Member Advocates
Prevention and Wellness
Patient Centered Medical Homes
Readmission Prevention
ED utilization, inpatient admission & readmission reports
HEDIS 21

22. Provider Credentialing
The Aetna Better Health of Nebraska credentialing process will be monitored by a Aetna Better Health of Nebraska dedicated Credentialing Coordinator
Contact your Provider Relations representative to initiate credentialing of a new provider
Please remember to contact the Coventry Commercial plan
Aetna utilizes the CAQH online, universal application
Aetna Better Health of Nebraska will not be able to assign retroactive effective dates for new providers 22

23. Provider Manual
The provider manual is a resource for policies and procedures for Aetna Better Health of Nebraska
Access it online at:
Please review this manual for additional information about Aetna Better Health of Nebraska including:
Contacts
Provider rights and responsibilities
Credentialing
Member eligibility and enrollment
Billing and claims
Reconsiderations, appeals and grievances 23

24. NDC Validation
The State of Nebraska determines which codes are required to be billed with NDC information. 
If a CPT/HCPCS code which requires an NDC is billed, but no NDC information is present, the claim line will be denied.
NDC information submitted on a claim is validated against a standard NDC dataset (MediSpan is the source of this dataset) to validate that the NDC number, unit of measure, and quantity is valid. 
Deactivated or terminated NDCs cannot be accepted.
The approved unit of measure (F2, GR, ML, UN, or ME) must be billed. 

25. NDC Validation (Continued)
If a NDC is submitted when not required by the State of Nebraska for drug rebate submission, it will still be validated for accuracy. 

26. NDC Continued
Effective December 22, 2014, Aetna Better Health will begin reviewing NDC dosage information. When an NDC is required, a dosage is required to be sent with the NDC information.  If the dosage is over or under the standard dosage limits, medical records will be required to process the claim.  If records are not sent, the claim line will be denied.  If a claim is denied, please resubmit the claim with medical records and a reconsideration form

27. EPSDT Modifier and Referral Indicator Codes
For Early and Periodic Screening, Diagnostic, and Treatment (EPSDT or Health Check) services, it is essential to bill these codes with an EP modifier.  EPSDT services not billed with the EP modifier will result in a claim line denial. 
In addition, one of the following referral indicator codes must be included on claims using CPT well-child preventive codes with the required EP modifier. (Electronic 837P or CMS 1500 box 24H).  

28. EPSDT Modifier and Referral Indicator Codes (Continued)
AV - Patient refused referral S2 - Patient is currently under treatment for diagnostic or corrective health problem NU - No referral given ST - Referral to another provider for diagnostic or corrective treatment

29. VFC (Vaccines for Children)
VFCs are not required to be billed with NDC information.  The following codes are excluded from NDC validation: 90471, 90472, 90473, 90474, 90633, 90649, 90658, 90707, 90710, 90716, 90734, 90664, 90666, 90667, 90668, 90648, 90669, 90681, 90713, 90721, 90748, 90650, 90718, 90685, 90660, 90686, 90655, 90656, 90657, 90670, 90714, 90715, 90744, 90746, 90647, 90672, 90680, 90696, 90698, 90700, 90723
Additional information for UB Billing
NDC information is required for specific revenue codes (0250, 0251, 0252, 0254, 0631, 0632, 0634, 0636, 0637) and bill type combinations ( , , or ). 

30. Web Portal Demo
Aetna Better Health of Nebraska is hosting webinar sessions to assist providers with functions of the secure provider web portal: Any provider who wishes to participate will need to register. Please us with your name, address, date & time preferred. All registered providers will receive an invitation to the webinar with further instructions the day prior to the scheduled webinar. Please check provider news for dates and times.

31. Thank you
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