Call a licensed agent at 1-855-335-1407 (TTY: 711) , 7 days a week, 8 AM to 8 PM. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. Specifically, Aetna uses information our members voluntarily provide to: Yes. Treating providers are solely responsible for dental advice and treatment of members. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. Has a process for monitoring, evaluating and improving the quality and safety of care provided to its members, Reports audited HEDIS results for designated HEDIS. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". ncqa, Find opportunities to ensure equitable access to health care. NCQA Health Plan Accreditation is a widely recognized, evidence-based program dedicated to quality improvement and measurement. (NCQA). Establish a baseline representative of the demographic composition of Aetnas membership; and. Some subtypes have five tiers of coverage. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. Cost: $449 Date: Wednesday, September 14, 2022; 1-4pm ET NCQA Health Equity Accreditation Plus. NCQA Certification products represent a subset of the standards and guidelines for our Accreditation products and are appropriate for organizations that provide specific services, but not comprehensive programs. Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. startxref The accreditations come after Aetna Better Health of Michigan, Inc., participated in an eight-month NCQA sponsored pilot to develop its Health Equity Accreditation Plus evaluation program. and Compliance, Evidence-Based Credentialing Accreditation is for organizations that provide full scope credentialing services. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. 0000007276 00000 n Unlisted, unspecified and nonspecific codes should be avoided. Interested in other accreditation options? At least 9 months in advance: Conduct an analysis comparing current processes to NCQA requirements and adjust as necessary. The information contained in this article concerns the MCG care guidelines in the specified edition and as of the date of publication and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date . HRA, At least 9 months before desired survey start date: Begin the online application process. Medi-Cal Managed Care Health Plan (MCP) Accreditation Status August 2019. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. Kristine is based out of Ventura County, California, United States and works in the Hospitals and Health Care industry. 12 months in advance: Become familiar with NCQA's required standards and processes. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. We are committed to improving services for preventive health, early detection and disease management for health conditions commonly seen in specific racial or ethnic groups. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The AMA is a third party beneficiary to this Agreement. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Providing employees of all racial and ethnic backgrounds with access to quality health care benefits and resources can help them stay healthy. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. #IP#@w"+;#j}2%0Z2 Health benefits and health insurance plans contain exclusions and limitations. Patient-Centered Medical Home (PCMH) Health Plan Accreditation HEDIS Measures Health Innovation Summit HRA, 0000018406 00000 n 0000002094 00000 n Work with HealthHUB, MinuteClinic and Network to bring licensed clinical social workers in to stores and offer new services, such as life coaching. As one of the nations leading health plans, Aetnas members represent the countrys increasing diversity in race, ethnicity and language. Please be sure to add a 1 before your mobile number, ex: 19876543210, follow-up care for children prescribed ADHD medication (ADD), screen for co-existing mental health and substance use disorders, Measure, monitor and improve clinical care and quality of service, Launch company-wide initiatives to improve the safety of our members and communities, Make sure we obey all the rules, whether they come from plan sponsors, federal and state regulators, or accrediting groups, Developing policies and procedures that meet clinical practice standards, Reviewing preventive and behavioral health services and how care is coordinated, Addressing racial and ethnic disparitiesin health care that could negatively impact quality health care, Monitoring the effectiveness of our programs, Studying the accessibility and availability of ournetwork providers, Monitoring the overuse and underuse of services for our Medicare members, Performing credentialing and recredentialing activities, Assessing member and provider satisfaction. Organizations that earn a seal from NCQA show that they are serious about quality health care. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass. Weve improved every year from 2017 through 2021 in our Healthcare Effectiveness Data and Information Set HEDIS measures and. Our quality improvement program helps improve the behavioral health care we provide to you. Some organizations may already be working within NCQA guidelines. You are now being directed to CVS Caremark site. CPT only Copyright 2022 American Medical Association. NCQA Credentialing Accreditation means that the caliber of the CVO's credentialing process is first-class. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Improved our patient safety programto help members make informed health choices, Used social media to share patient safety information, Provided patient safety resources to physicians on the secure provider website. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. Any organization that provides managed health care services can apply for the NCQA Health Plan Accreditation if it meets the following criteria: The first step to earning accreditation is a discussion with an NCQA program expert. CPT is a registered trademark of the American Medical Association. ,) V-Wz/"HESru66x k#1:1eM8Q g`$d(d|jJ\]7CY]h:tUf5u{;=== fJ*F=(W3OiLz}mLT EN"TPrr5[U1 UEpQ_(!`9%1pcrYfgNrLB,e~'usgg=E@gIU wFGfMK_* T@F2w\0t~Xx[J4pKqa}o* ]xqx03P^=NcjdU1al7%D2y'AL,,UB,b6 Download our case study to learn how vendors earn NCQA certification, and the value this recognition has brought toWellsourceclients for over a decade running. Notification to Authorities and Practitioner Appeal Rights. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. All Rights Reserved. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Copyright 2015 by the American Society of Addiction Medicine. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Here's what we did in 2021: Enhancing health and mental well-being leads to a better quality of life. Companies use NCQA-certified HRAs and self-management tools because they know they provide quality data and a quality experience for the individuals who take them. The typical evaluation time frame is 12 months from application submission to decision, depending on an organizations readiness. When health plans work with vendors that have already passed NCQAs thorough review, they receive oversight relief for all the standards that apply. The review process is rigorous and may consist of both an onsite and offsite evaluation. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Help gain accreditation by the National Committee for Quality Assurance (NCQA) and other accreditation organizations. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. When billing, you must use the most appropriate code as of the effective date of the submission. We launched our Caring Contacts program to provide resources and support to Aetna members discharged from an inpatient setting after a suicide attempt. xb``c``y 3Ps400(e A1$/G #G JReqw@36&c`yXEH10FC PC It is only a partial, general description of plan or program benefits and does not constitute a contract. Health plan accreditation requires the use of HRAs and self-management toolsand though organizations seeking accreditation can opt to build their own HRA or partner with a third-party for the solution, many find themselves weighing the pros and cons of building their own solution and opting instead to partner with a trustworthy vendor. Build vs. Buy: Which Health Risk Assessment Approach is Right for You. Together with Autism Comprehensive Educational Services (ACES), weve created the first Aetna Institute of Quality (IOQ) for autism. NCQA Credentialing Accreditation is a comprehensive program that evaluates the operations of organizations providing full-scope credentialing services, which include verifying practitioner credentials, designated credentialing-committee review of practitioners and monitoring practitioner sanctions. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). We launched MinuteClinic HealthHUB pilots across four states to demonstrate CVS Healths commitment to mental health and access to mental health services and resources. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Credentialing services include: Verifying healthcare provider credentials through a primary source or a contracted agent of the primary source. The standards focus on: Quality Management and Improvement Population Health Management Network Management In 2019, NCQA rated more than 1,000 health insurance plans based on clinical quality, member satisfaction and NCQA Accreditation Survey results. Accreditation Process and Timeline: Key steps, timing and resources for a successful accreditation. Understand your population's health risks and improve health outcomes. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Members also told us the information they learned from the program had a positive effect on their lives, and their health improved because of the program. We worked with BrandWatch to get social media analysis of mental health findings for adolescents and LGBTQ/BIPOC youth. Purchase and review the program resources, conduct a gap analysis and submit your online application. Each year, we use the results to set new goals and improve selected measures. The National Committee for Quality Assurance's (NCQA) Diabetes Recognition Program (DRP) recognizes clinicians who have met standards demonstrating delivery of high-quality care to patients with diabetes. NCQA Accreditation as of June 30, 2022. URL: www.aetna.com. Copyright 2023 National Committee for Quality Assurance. The accreditation process takes an average of 12 months and is the only healthcare industry program that bases results on clinical performance and consumer experience. Go to the American Medical Association Web site. The member's benefit plan determines coverage. Obtain full pricing information by submitting a request through My NCQA. 0000014217 00000 n Provides services through an organized delivery system that includes ambulatory and inpatient health care sites. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. If you do not intend to leave our site, close this message. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. The typical evaluation time frame is 12 months from application submission to decision, depending on an organizations readiness. Save your favorite pages and receive notifications whenever theyre updated. %%EOF 0000004508 00000 n An organization that earns Accreditation meets standards covering more than 100 measured elements. ncqa, trailer This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Through the accreditation process, organizationsare able toperform a gap analysis and identify areas for improving their evidence-based practices. This Agreement will terminate upon notice if you violate its terms. Satisfaction remained high, and members are likely to recommend the program. Engage members through pre-clinical coaching to address mental health issues before they become a crisis. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. It's how we show our commitment to improving your quality of care, access to care and member satisfaction. At the very least, patients must be given tools that help them to speak more confidently and effectively with their health care providers so that they can take greater control of their health and well-being. We use information our members voluntarily provide to create our Racial and Ethnic Equity Dashboard (REED) report. Star ratings were created to help beneficiaries assess their care needs against the quality of Medicare Advantage health plans care and service. We launched an evidence-based 12-week pilot program with OUI Therapeutics/Vita Health for adults 18+ delivered virtually by clinical specialists to help lower suicide risk. Maintain Your License. Share this page with a friend or colleague by Email. Save your favorite pages and receive notifications whenever theyre updated. CPT only copyright 2015 American Medical Association. 0000001781 00000 n 0000018200 00000 n Interactive Survey Tool: Contains the complete standards and guidelines; you can also determine your organizations survey readinessthe tool calculates your potential survey score. Align your organization's processes with the standards. Such data can lead to the development of specific initiatives that improve the health of people of various backgrounds based on their risks for certain conditions. 0000001025 00000 n All services deemed "never effective" are excluded from coverage. In the past, health plans like Aetna have not systematically collected data on race and ethnicity. 0000007519 00000 n If you have questions about a Med Premier major medical plan, call The Boon Group at the toll-free number on your member ID card. Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. Some subtypes have five tiers of coverage. Measure the performance and outcomes of our programs and processes. Categories include: Find the Standards and Guidelines document in the NCQA Store. trailer /Size 49 /Info 8 0 R /Root 10 0 R /Prev 21523 /ID[060e888545013965100abd54e3afe5c1>060e888545013965100abd54e3afe5c1>] >> startxref 0 %%EOF 10 0 obj /Type . 0000002555 00000 n Wellsource, Topics: *NCQA-Accredited health plans or MBHOs are eligible for Accreditation in UM, CR or PN if they also maintain health plan or MBHO Accreditation. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Standards and Guidelines: The complete standards and guidelines, including the intent and scope of review. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. kBtUp+v;J~)k>x@4l1%RuMALe0>6L(h(yI nL`suT;,y=PO#f{{0!4H6ISwB1"`rX`\'J$tS In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Request an application. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. 1 Based on results from the 2021 Aetna Case Management Member Satisfaction Analysis. xref Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. OTHER NAMES FOR THIS HEALTH PLAN. Collect, maintain and present data on race and ethnicity that leads to the development of effective member education, health prevention and patient care management programs. The ABA Medical Necessity Guidedoes not constitute medical advice. Legal notices More than 1,000health plans have earnedNCQA Accreditation and achieving accreditation is a lengthy process, representing a lot of work. Quality Compass is a registered trademark of NCQA. As described above, seeking accreditation is anarduous process. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. NCQA requirements are a roadmap for improvementorganizations use them to perform a gap analysis and align improvement activities with areas that are most important to states and employers, such as network adequacy and consumer protection. health plans, Don Hall, DrPH, CHES, Founder The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. For language services, please call the number on your member ID card and request an operator. NCQA's Health Plan Accreditation program builds on almost three decades of experience measuring the quality of health plans. Links to various non-Aetna sites are provided for your convenience only. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. No fee schedules, basic unit, relative values or related listings are included in CPT. More than 1,000 health plans have earned NCQA Accreditation and achieving accreditation is a lengthy process, representing a lot of work. The NCQA process was Implemented effective 3/1 8/2020 by the Credentialing Department at Aetna Better Health of Louisiana. Submit the Application and Pay the Application Fee. New and revised codes are added to the CPBs as they are updated. Terms of Use, Patient-Centered Specialty Practice (PCSP), Credentials Verification Organization (CVO), Managed Behavioral Healthcare Organization (MBHO), Health Information Technology Prevalidation Programs, Virtual Seminars, Webinars and On-demand Training, Advertising and Marketing Your NCQA Status. 45 26 Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT"). have relied on Wellsource for innovative, evidence-based, NCQA-certified health risk assessment solutions to 0000004583 00000 n Wellsource:NCQA Certified, Committed toQuality andExcellence, Ready to learn more about the NCQA certification process? endstream endobj 46 0 obj <>/Metadata 5 0 R/PieceInfo<>>>/Pages 4 0 R/PageLayout/OneColumn/StructTreeRoot 7 0 R/Type/Catalog/Lang( E N - U S)/LastModified(D:20091014145733)/PageLabels 2 0 R>> endobj 47 0 obj <>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>>/Type/Page>> endobj 48 0 obj [49 0 R] endobj 49 0 obj <>/A 57 0 R/F 4/H/I/StructParent 1/Border[0 0 0]/Type/Annot>> endobj 50 0 obj <> endobj 51 0 obj <> endobj 52 0 obj [/ICCBased 58 0 R] endobj 53 0 obj <>stream

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