December 21, 2018

Dear Provider,
 
 
Recently, Aetna Better Health of Ohio implemented a change to our pre-denial notice that included language on the peer-to-peer opportunity. We understand we made the change very quickly and without prior notice. We apologize for the challenge and current frustration this change has caused.
 
The change in our pre-denial notification primarily affects expedited pre-service requests. We determined that in the case of a communicated denial, the proposed follow-up time for a peer-to-peer discussion was inconsistent with our policy. Our policy language for Concurrent Review reads as follows: "Peer-to-peer review for MMP Duals program Concurrent Review (including LTACH, SNF, lP Rehab and Acute Hospital to Hospital transfers) is only available prior to a denial of coverage determination."
 
In Ohio, we must finalize and communicate in writing our denials for expedited requests within 48 hours. After you have received our notice to participate in a peer-to-peer discussion, and a decision has been determined that you do not agree with, then your next step will be to follow the appeal process. A discussion can occur after the denial has been communicated, but that discussion cannot result in a re-opening of the request.
  
Please be reminded that any denial may still be appealed through the required process for pre-service appeals.
 
We again apologize for the inconvenience for the immediate change in the pre-denial communication. We will continue to work towards building a collaborative partnership with you and are committed to improving our timing and communications to all of you when conditions require a change in our processes.
 
To assist providers, we've constructed the below Frequently Asked Questions related to our new policy.   If you have additional questions, please call us at 855-364-0974, press *, then say "Authorizations".
 
Sincerely,
 
Provider Services
Aetna Better Health® of Ohio

 
Utilization Management FAQ's for Providers
Q: If a provider sends in a case marked as Urgent or expedited, what is the turnaround time of the case?
A: If the case is deemed to be expedited in nature by the plan, the case will be resolved within 48 hours. This is the requirement of Ohio Senate Bill 129 and our 3 way contract: 2.8.4.5.2. "For expedited service authorization decisions, where the Provider indicates and the ICDS Plan determines that following the standard timeframe in Section 2.8.4.5.1 above could seriously jeopardize the Beneficiary's life or health or ability to attain, maintain, or regain maximum function, the ICDS Plan must make a decision and provide notice as expeditiously as the Beneficiary's health condition requires and no later than seventy-two (72) hours after receipt of the request for service, and effective January 1, 2018 no later than forty-eight (48) hours after receipt of the request for service.")
The provider and member will be notified of the decision.
Q: The provider sent in a non-urgent request for inpatient authorization. What is the turnaround timeframe for this decision to be rendered?
A: The plan understands the urgency related to providers having determinations for these requests. To that end, the provider should have a decision as soon as possible, but within 72 hours from receipt of the request.
Q: If a provider sends in a case and does not designate it expedited in nature, what is the turnaround time of the case?
A: The UM staff will determine if the case needs to be classified as expedited based on CMS guidance. If it is not considered expedited, and is not inpatient, the case will be resolved within 10 days.
Q: Are there any actions necessary for providers to comply with service request processing?
A: Yes. All decisions related to medical necessity are made using clinical information received from the provider. It is very important that all clinical information needed to make the decision be sent in with the case.
Q: The provider received fax or call of the intent to deny a service request. Can the provider have a peer to peer discussion?
A: Yes.   All decisions related to expedited requests must be made within 48 hours. This includes clinical review and peer to peer, if a peer to peer is requested. The plan will make accommodations for peer to peer discussion within the CMS decision timeframes. Decisions cannot be changed once they have been completed in our systems. Peer to peer can occur after the decision is completed, but will have no bearing on the decision.   The provider must provide necessary clinical information in order for the plan to make a timely decision. For adverse decisions, our members receive information related to their appeal rights.
Q: What is considered an expedited service?
A: Chapter 13 of the Medicare Managed Care Manual covers the definition. (Section 50) Additionally, the plan will review the request and if it does not meet CMS criteria can be downgraded to a standard request.

 
 
 
Provider Services
Aetna Better Health of Ohio



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