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Summer 2020
Stay in the Know About Coronavirus

Find timely information to support your patients through telemedicine, testing, COVID-19-related coding, and other resources we are sharing to help you during this pandemic.
Additional Medicaid Resources
Additional questions and feedback regarding Medicaid policy can be directed to [email protected]
OhioMHAS-certified providers can contact [email protected] .
Additional COVID-19 information and resources can be found at coronavirus.ohio.gov or by calling 1-833-4-ASK-ODH (1-833-427-5634).
Appointment Availability Standards & Timeframes    

Providers are required to schedule appointments for eligible enrollees in accordance with the minimum appointment availability standards and based on the acuity and severity of the presenting condition, in conjunction with the enrollee's past and current medical history. Our Provider Services Department will routinely monitor compliance and seek Corrective Action Plans (CAP), such as panel or referral restrictions, from providers that do not meet accessibility standard. Providers are contractually required to meet the Ohio Department of Medicaid (ODM) and the National Committee for Quality Assurance (NCQA) standards for timely access to care and services, considering the urgency of and the need for the services.
 
The table on the below shows appointment wait time standards for Primary Care Providers (PCPs), Obstetrics and Gynecologist (OB/GYNs), high volume Participating Specialist Providers (PSPs), and Mental Health Clinics and Mental Health/Substance Abuse (MH/SA) providers.

 
Provider Type
Emergency Appointment Timeframe
Urgent Appointment Timeframe
Routine Appointment Timeframe
Appointment Wait Time (Office Setting)
Primary Care
Same Day
Within 2 calendar days
Within 3 weeks
No more than 60 minutes
Specialist Care
Immediate
Within 2 calendar days
Within 3 weeks
No more than 60 minutes
OB/GYN
Immediate
Within 2 calendar days
Initial Prenatal Care
  • 1st Trimester: Within 3 weeks
  • 2nd Trimester: Within 7 calendar days
  • 3rd Trimester: Within 3 calendar days
  • High Risk: Within 3 days
  • Routine Care: Within 3 weeks
  • Postpartum Care: Within 6 weeks
     
Behavioral Health
Potentially suicidal individual: immediate treatment
 
Non-life threatening emergency: within 6 hours
Within 48 hours
No more than 60 minutes
EPSDT (Early Periodic Screening Diagnosis & Treatment)
No more than 60 minutes
Physical Therapy
Within 24 hours
Within 72 hours
No more than 60 minutes
Occupational Therapy
Within 24 hours
Within 72 hours
No more than 60 minutes
Sports Medicine
Within 24 hours
Within 72 hours
No more than 60 minutes
Audiology
No more than 60 minutes
Financial Liability for Payment for Services

Balance billing enrollees is prohibited under the MyCare Ohio plan. In no event should a provider bill an enrollee (or a person acting on behalf of an enrollee) for payment of fees that are the legal obligation of Aetna Better Health of Ohio. This includes any coinsurance, deductibles, financial penalties, or any other amount in full or in part. Providers must make certain that they are:
  • Agreeing not to hold enrollees liable for payment of any fees that are the legal obligation of Aetna Better
  • Health of Ohio, and must indemnify the enrollee for payment of any fees that are the legal obligation of Aetna Better Health of Ohio for services furnished by providers that have been authorized by Aetna Better Health of Ohio to service such enrollees, as long as the enrollee follows Aetna Better Health of Ohio's rules for accessing services described in the approved enrollee Evidence of Coverage (EOC) and or their Enrollee Handbook.
  • Agreeing not to bill an enrollee for medically necessary services covered under the plan and to always notify enrollees prior to rendering services.
  • Agreeing to clearly advise an enrollee, prior to furnishing a non-covered service, of the enrollee's responsibility to pay the full cost of the services.
  • Agreeing that when referring an enrollee to another provider for a non-covered service, provider must make certain that the enrollee is aware of his or her obligation to pay in full for such non-covered services
HEDIS 2020 Wrap-Up & Quality Navigator Webinars

Thank You for Your Participation in HEDIS 2020!
Aetna Better Health of Ohio completed our annual Healthcare Effectiveness Data and Information Set (HEDIS) medical record collection process the first week of April 2020 due to a mandate from CMS to stop HEDIS data collection in the midst of a worldwide pandemic. We are sincerely grateful for our dedicated provider community. We appreciate your partnership in this effort by you and your staff in your timely responses to our requests for medical records and allowing our review nurses to complete on-site appointments.  We look forward to continuing to work with you for many years as we join our members in receiving the best care for better health.

In preparation for the next HEDIS data collection period based on calendar year 2020 data, we encourage you to participate in our free Quality Navigator monthly webinars.  The goal of the webinar series is to:
  • Educate on HEDIS measures
  • Explore ways to cut down on the burden of medical record review and maximize administrative data capture
  • Present NCQA HEDIS reporting codes that will effectively capture care
  • Discuss HEDIS measures applicable to certain populations
  • Open discussion to see how other providers are addressing HEDIS and barriers to care
  • Strategies for improvement
  • Connect you with a single point of contact at the health plan for HEDIS/Quality questions
Check your inbox for monthly invites and registration information.  If you are not currently receiving the invitations and would like to start receiving them, please send via email your name and email address to your Provider Relations Liaison to be added to the list. 
The calendar for the remainder of 2020 is as follows:
July 2020
HEDIS Measures, healthcare, and EPSDT for members age 12 to 20
 
August 2020
Takeaways from HEDIS 2020 and preparing for HEDIS 2021 data collection
HEDIS and caring for members with developmental disabilities
 
September 2020
Coding specific topic: Closing HEDIS gaps in care administratively
The correlation between substance abuse and mental illness
 
October 2020
HEDIS Measures for women, breast cancer screenings, and maternity care
 
November 2020
HEDIS Measures of care for male and female members over the age of 21
 
December 2020
Reducing the burden of medical record review and preparing for HEDIS 2021 data collection
 
For HEDIS related questions contact our HEDIS Help Line at 855-750-2389.
HEDIS® Highlight: Transitions of Care Measure   
The MyCare Ohio population includes older adults and individuals with complex health needs who often receive care from multiple providers and settings. This population is at particular risk during transitions of care because of higher comorbidities, declining cognitive function and increased medication use.1  Hospital transitions require clear communication between inpatient and outpatient providers to ensure optimal health outcomes during patient handoffs.
Effective care coordination efforts are being measured by Aetna Better Health of Ohio through the Transitions of Care HEDIS measure.2  Four rates are reported based on the percentage of discharges for patients 18 years of age and older where there is evidence of:
  1. Notification of patients' primary care practitioners (PCPs) or ongoing care providers of admission on the day of admission through 2 days after the admission
  2. PCPs/ongoing care providers receipt of meaningful and timely discharge information on the day of discharge through 2 days after the discharge
  3. Patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days post- discharge.
  4. Medication reconciliation on the date of discharge through 30 days after discharge.

How provider offices can help meet measure compliance:
  • Ensure clear evidence of date of receipt of admission notification and discharge information in medical record
  • Ensure method of receipt is available/operational over holidays and weekends (e.g. fax machine)
  • Utilize a health information exchange, automated alert system or shared EMR (a shared EMR is considered the PCP or ongoing care provider's record)
  • Follow up on any provider referrals to the ER: a referral to the ER does not count as notification if the ED visit results in inpatient admission. Accept notification directly from the inpatient facility (not hearsay from patient, patient's family, or caregiver)
  • Document provider awareness or acknowledgement of the inpatient stay at the time of post-discharge patient engagement and medication reconciliation
  • Complete patient engagement within 30 days post discharge (but not on the day of discharge)
  • Ensure presence of and reference to a current listing of medications in the record for medication reconciliation with discharge medications to be counted
  • Ensure medication reconciliation is documented in the record (an outpatient visit is not required)
  • Ensure medication reconciliation is completed and signed by either a prescribing practitioner, clinical pharmacist, or registered nurse
HEDIS is a registered trademark of the National Committee for Quality Assurance.
1"NCQA, "Transitions of Care Measure", HEDIS MY 2020 & MY 2021, Vol 2, Technical Specifications for Health Plans (Accessed 7/13/20)
2Vognar, L., and N. Mujahid. 2015. "Healthcare transitions of older adults: An overview for the general practitioner." Rhode Island Medical Journal http://www.rimed.org/rimedicaljournal/2015/04/2015-04-15-ltc-vognar.pdf
Fee Table

Providers must bill according to CMS and Medicaid guidelines. It is also the provider's responsibility to be familiar with the latest billing practices.   Aetna is not responsible for instructing providers how to correctly bill for services.  
 
Also, providers should frequently check the state's  Fee Schedule & Rates  website as updates are always occurring to the fee schedules for Medicaid.




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