Aetna Better Health of New Jersey publishes provider notices containing up-to-the-minute information you may need to know from our regulators, new coding/claims processing rules, or any other new plan information. Our goal is to keep you as well informed about our plan as possible. Be sure to check this page often.
Subject: New Policy Updates - Clinical Payment, Coding and Policy Changes
Date: July 1, 2019
We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes. In an effort to keep our providers informed, please see the below chart of upcoming new policies.
Effective for dates of service beginning Q4 2018
DIAGNOSIS CODE GUIDELINES-ICD10 EXCLUDES 1 NOTES-One of the unique attributes of the ICD-10-CM code set is the new concept of Excludes 1 Notes. An Excludes 1 Note indicates that the excluded code identified in the note should never be used at the same time as the code or code ranges above the Excludes 1 Note in the ICD10 manual. An Excludes 1 Note is used to indicate when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. These conditions are mutually exclusive code combinations.
Per ICD-10 Manual 2019, under section E03 (Other Hypothyroidism), there is an “Excludes 1 Note” E89.0 (Postprocedural hypothyroidism) and E00-E02 (Iodine-deficiency related hypothyroidism); as these 2 diagnoses represent mutually exclusive conditions with different origin and cannot be reported together.
Per the 2019 ICD-10 Manual page 1067, Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes lists T43- (Poisoning by, adverse effect of and underdosing of psychotropic drugs, not elsewhere classified) with an “Excludes 1 Note” for T42.4- (Poisoning by, adverse effect of and underdosing of benzodiazepines). As one is specific (“benzodiazepines”) and one is “not classified elsewhere” these two diagnoses are mutually exclusive and cannot be reported together.
Subject: Medical Record Request Requirement
Date: February 6, 2018
As we enter HEDIS season, Aetna Better Health of New Jersey would like to remind providers of our medical record request requirement:
Health Care Providers must supply copies of records within 14 days of the receipt of a request, where practicable, and in no event later than the date required by any applicable law, regulatory authority or government agency with jurisdiction over Aetna Better Health’s operations (a “Government Sponsor”). Except as required by applicable state or Federal law, Aetna Better Health (including Aetna Better Health’s authorized designee), Government Sponsors and Aetna Better Health members shall not be required to reimburse Health Care Providers for expenses related to providing copies of patient records or documents.
Thank you for your continued commitment to improving the health of our members – your patients.
Subject: Provider Notification: Unlisted Code
Date: August 8, 2017
Effective September 15, 2017, Aetna Better Health of New Jersey will change the way unlisted and non-specific CPT and HCPCS codes are reviewed and paid.
With a few exceptions listed below, these codes will no longer be managed through the prior authorization process. They will be managed with Medical Records at the time of claim submission. That is, records supporting the use of these codes must be submitted with the claim. These claims will pend to our AMA Edit Team who will review for:
- Experimental/Investigational status per relevant Aetna CPB (www.aetna.com/health-care-professionals/clinical-policy-bulletins.html); and
- Medical necessity applying relevant criteria; and
- Assignment of a more appropriate specific code if one exists; or
- Approval to pay as submitted.
Codes not included in the process change are:
41899 – General Anesthesia for dental procedures
E1399 and K0108 – wheelchair components and services
90999 – unlisted dialysis procedure
Prior Authorization with dialysis services
Unlisted J code
If records are not submitted with any claim including one of the codes listed below, the claim will be denied for lack of documentation. You may resubmit the claim with required supporting records.
Please refer to the list for the codes covered by this process.
Subject: FluMist No Longer Covered
Date: September 1, 2016
Aetna Better Health of New Jersey covers all vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP). ACIP regularly reviews all formulations of vaccines and updates its list of recommended vaccines. In previous years, the list included a live attenuated Influenza vaccine (LAIV) for individuals aged 19-49 in a nasal spray formulation (Flumist). Recently the ACIP determined that the current LAIV should not be used for the 2016-2017 Influenza season.
As a result of the decision by ACIP, Aetna Better Health of New Jersey will no longer cover LAIV for prevention of influenza for the 2016-2017 Influenza season. ACIP continues to recommend annual flu vaccination with either the inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) for everyone 6 months and older. Injectable Seasonal Influenza Vaccines (Trivalent and Quadrivalent) and Intradermal Influenza Vaccine (Short Needle) will continue to be covered during the current Flu Season of August 1, 2016 –April 30, 2017. These vaccines are available through a participating pharmacy. View the CDC Newsroom Media Statement.
Subject: Fluoride varnish
Date: Oct. 21, 2015
Aetna Better Health on New Jersey encourages medical providers to apply fluoride varnish to children’s teeth, perform dental assessments and promote routine oral heath visits for Aetna’s young members.
- Participating pediatricians, nurse practitioners and physician assistants who have completed an online training curriculum or who have received training from an already trained provider can be reimbursed for the application of fluoride varnish.
- Pediatricians will be reimbursed $15 for each varnish application every three months on members up to age five.
- Enter CPT code 99188 and ICD-10 diagnosis code Z00.12X or Z76.2 on the claim form when billing Aetna. Only trained providers will be reimbursed.
- Online training can be completed at www.smilesforlifeoralhealth.org/. Click course 6: Caries Risk Assessment, Fluoride Counseling on the right side column. One provider per facility needs to complete the online curriculum and can then train their colleagues.
- Providers who have completed the training must sign a form attesting they have completed the curriculum. The form is on our website. Please FAX the form to Joseph Maggio 1-860-607-8842.
- Fluoride varnish supplies can be obtained by contacting Henry Schein at 1-800-372-4346 or Benco at 1-800-462-3626.