It takes some of the guesswork out of billing, and may support reprocessing or appeal. When you request benefits for an Aetna patient, include any Dx codes you plan to bill. What does that mean for healthcare providers? When employer groups write their own coverage policies, coverage and diagnosis restrictions can differ greatly from one employer to the next.
Some employer group plans are more restrictive than Aetna’s corporate standard, while others are more inclusive, allowing a wider range of diagnoses and procedures. Many employer groups are writing their own coverage policies for acupuncture. In 2018, we’ve seen a notable increase in the number of employer group plans that allow acupuncture, but do not follow CPB #0135. It provides a list of approved procedure (CPT) and diagnosis codes that can be used when billing acupuncture for an individual plan.įor the last several years, employer group plans have usually followed the guidelines listed in CPB #0135.īut we recently identified an emerging trend that affects many new Aetna patients. For Aetna patients with an individual plan, CPB #0135 is an invaluable resource. As Acubiller’s benefit team researches policy information for our growing client base, we look for emerging trends in coverage.Īetna’s corporate coverage guidelines for acupuncture are laid out in Clinical Policy Bulletin #0135. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.If there’s one thing we can count on in the American insurance industry, it’s change.īilling techniques, filing requirements, and policy details can (and often do) change dramatically from year to year. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage.
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. 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. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. By clicking on “I Accept”, I acknowledge and accept that:
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