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. Amounts include those applied toward deductibles, coinsurance amounts, copayments and any write-offs.īy clicking on “I Accept”, I acknowledge and accept that: Line-level-adjustment reason codes and associated amounts (professional claims only): These show why the other insurer paid less than billed. ![]() Patient-paid amount: These amounts include those applied toward deductibles, coinsurance amounts and copayments.Be sure you don’t confuse the payer-paid amount with the patient-paid amount. This amount is equal to total charges minus claims and line-level adjustments. Payer-paid amount: When we pay second, we need to know the amount the primary carrier paid you.The other employer’s name, if applicable.The other plan’s policy number, if applicable.Here are the fields we’re reviewing when the patient has another insurance plan, and we’re paying second: That takes time and may delay processing your claim. If you enter any incorrect information, we must verify the information ourselves. Don’t enter non-COB information, such as information on discount programs or life insurance, in those fields. If the patient has no other coverage, we ask that you leave those fields blank. Check with your software vendor to ensure you’re entering the information in the correct fields to transmit to us.) (We’re looking for this information in the 23 loops of the electronic claim transaction. Once you learn about their other coverage, we’ll need some information on the patient’s primary plan and what they may have already paid you. Without that information, your claim payments could be denied or delayed. And when we process claims faster, you could get your claims payments faster, too.įirst, ask your patients whether they have other coverage. ![]() When you send us the right information up front, we process your secondary claims faster. Did you know that we can accept your secondary, or coordination of benefits (COB), claims electronically, too? In fact, we prefer that you send us your secondary claims electronically. You’re already sending us your primary claims electronically. Tips for submitting secondary claims electronically
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