Claims

You’ll need to fill out a claim form. Use the provider ID 128LA for both CMS 1500 and UB 04 forms.

You must file claims within 180 days from the date you provided services, unless there’s a contractual exception. For inpatient claims, the date of service refers to the member’s discharge date. You have 180 days from the paid date to resubmit a revised version of a processed claim. 

You can file claims for retro members through the normal claims process. These are members who are retroactively eligible for coverage.  

Online

Availity is our provider portal, which provides functionality for the management of patients, claims, authorizations and referrals. To submit claims online via Availity, choose the button labeled “Medicaid Claim Submission – Office Ally.” This link will take you directly to the Office Ally website where you can submit claims using their online claim entry feature or by uploading a claim file.

Providers must have an Office Ally account to submit claims online. Submission of your Aetna Better Health of Louisiana claims using Office Ally is free of charge. The status of claims submitted online should be managed through your Office Ally Account.

By mail

You can also mail hard copy claims or resubmissions to:

Aetna Better Health of Louisiana 
Claims and Resubmissions 
P.O. Box 982962
El Paso, TX 79998-2962

Mark resubmitted claims clearly with “resubmission” to avoid denial as a duplicate. 

CMS-1500 sample (PDF)

UB-04 sample (PDF)

You may resubmit your claim for issues concerning nonclinical denials, missing information or a correction, and/or rate reimbursement disagreements.

Use this Provider Claim Resubmission Form (PDF) for the following reasons:

• Itemized Bill (mark the top of the claim “CLAIM FOR RESUBMISSION”)
  • All claims associated with an Itemized Bill must be broken out per Rev Code to verify charges billed on the UB match the charges billed on the Itemized Bill. (Attach I-Bill that is broken out by rev code with sub-totals.)
• Duplicate Claim (mark the top of the claim “CLAIM FOR RESUBMISSION”)
  • Review request for a claim whose original reason for denial was “duplicate”
  • Provide documentation as to why the claim or service is not a duplicate such as medical records showing two services were performed
• Proof of Timely Filing (mark the top of the claim “CLAIM FOR RESUBMISSION”)
  • For electronically submitted claims provide the second level of acceptance report
  • Refer to Proof of Timely Filing Requirements in the Provider Manual
• Coordination of Benefits (mark the top of the claim “CLAIM FOR RESUBMISSION”)
  • Attach EOB or letter from primary carrier
• Claim/Coding Edit (mark the top of the claim “CLAIM FOR RESUBMISSION”)
  • We use two claims edit applications: Claim Check and Cotiviti.
  • Refer to the Provider Manual for details.
• Corrected Claim (mark the top of the claim “CORRECTED CLAIM FOR RESUBMISSION”)
  • Must be received within 180 days of the date of service or discharge date
  • Newly added modifier
  • Code changes
  • Any change to the original claim

To resubmit a claim with missing information or a correction, mail claim and all supporting documentation appropriately labeled to the address specified on the form.

Note: Provider Claim Resubmissions do not include pre-service denials that were denied due to not meeting medical necessity. Pre-service denials are processed as member appeals and are subject to member policies and timeframes.

You can resubmit a claim through Availity or by mail. If you resubmit by mail, you’ll need to include these documents:

• Claim resubmission and dispute form (PDF)
• An updated copy of the claim — all lines must be rebilled
• A copy of the original claim (reprint or copy is acceptable)
• A copy of the remittance advice on which we denied or incorrectly paid the claim 
• A brief note describing the requested correction 
• Any other required documents

Both in-network and out-of-network providers have the right to appeal the result of a request for reconsideration. The claim reconsideration is the first step of the appeal process. For more information, refer to the Provider Manual.

Participating providers should follow the claim reconsideration followed by the appeals process:

• 1^st Level Appeal: Provider must submit the claim reconsideration verbally or in writing, within one hundred and eighty (180) days of the remittance advice paid date.

OR

• 2^nd Level Appeal: If the claim reconsideration was upheld, the Provider must submit the appeal request in writing, via mail, fax, or online within ninety (90) calendar days of the notice of denial.

AND

• Provide any additional or new clinical documents with the claim reconsideration or appeal.
• Aetna Better Health will take into account all documentation when rendering a decision on a claim reconsideration or appeal.
• When the claim reconsideration or appeal includes a medical necessity decision, it will be reviewed by the medical director who was not involved in the original denial
• A resolution letter will be mailed within 30 calendar days from receipt of the claim reconsideration or appeal
• Provider requests to appeal pre-service items on behalf of a member are considered member appeals and subject to the member appeal procedures and timeframes.

Your request for a claim reconsideration or appeal should include the appropriate form along with medical records to support your request. Do not submit the member’s entire medical record. Only submit the medical records relevant to your request and indicate which pages support your request. Submit your appeal through the option that is convenient for you.

You'll get a final determination letter with the appeal decision, rationale and date of the decision. We usually resolve provider appeals within 30 calendar days.

If the appeal decision isn’t in your favor, you can’t “balance bill” the member for services or payment that we denied for coverage. 

You can file an appeal:

By phone

Just call 1-855-242-0802 (TTY: 711).

By mail

You can send your appeal to:

Aetna Better Health of Louisiana  
Grievances and Appeals   
PO Box 81040  
5801 Postal Rd  
Cleveland, OH 44181 

By fax

Fax your appeal to 860-607-7657. 

By email

Email us your appeal.

The Independent Review process was established by La-RS 46:460.81, et seq. to resolve claims disputes when a provider believes we have partially or totally denied claims incorrectly. 

If we fail to send you remittance advice or other written or electronic notice (either partially or totally denying a claim) within 60 days of our receipt of the claim, this is a claims denial.

Independent review is a two-step process

1. Start by submitting an independent reconsideration review form within 180 calendar days of the remittance advice paid, denial, or recoupment date. We'll acknowledge receipt of the independent reconsideration review in writing within 5 calendar days and make a decision within 45 days of receipt.
   

    

   Complete the independent reconsideration review form (PDF), with all documentation, and send via email (preferred) or mail to:
   

    

   Aetna Better Health of Louisiana
   PO Box 81040
   5801 Postal Rd
   Cleveland, OH 44181 

2. You may then submit the independent review to the Louisiana Department of Health if we:

    

   • Uphold the adverse determination
   • Don’t respond to the independent reconsideration review request within the 45 calendar days allowed

   The fee for conducting an independent review is $750. If the independent reviewer renders their decision in:

    

   • Our favor: You’ll need to reimburse us for this fee within 10 days of the final decision.
   • Your favor: We’ll pay the disputed claims, along with 12% interest, within 20 calendar days of the final decision.

Submit a request for independent review

Complete the Louisiana Department of Health independent review request form.

 

Learn more about independent review

 

Send the completed request form with all required documents listed on the form via certified mail to the Louisiana Department of Health:

 

LDH/Health Plan Management

P.O. Box 91030, Bin 24

Baton Rouge, LA 70821-9283

Attn: Independent Review

 

Reminder: Don’t send medical records to the Louisiana Department of Health. The independent reviewer will contact you and Aetna Better Health to obtain all the necessary documents.