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Criteria availability
Criteria availability
Aetna Better Health® of New Jersey uses guidelines to make treatment authorization decisions. Providers and members have the right to request a copy of those guidelines or specific criteria. Just keep this disclosure in mind:
“The material provided to you are guidelines used by this plan to authorize, modify, or deny care for the person with similar illnesses or conditions. Care and treatment may vary depending on individual need and the benefits covered under your contract.”
Need a copy of the criteria? Just call Provider Services at 1-855-232-3596 (TTY: 711).
Affirmative statements about incentives
We base our utilization management (UM) decisions on appropriateness of care and service, subject to covered benefits. If we contract with practitioners and providers to make UM decisions, we require that they make decisions based only on appropriateness of care and service.
We don’t provide incentives or make financial arrangements that encourage staff or contracted providers making UM decisions to:
- Issue denials, limitations or discontinuation of medically necessary care
- Make decisions that lead to underutilization
This includes our policies and practices in:
- Hiring
- Compensation
- Termination
- Promotion
- Any similar matters
No penalties
We don’t take any action to penalize or discourage members or providers with regard to appeals, disputes or other disagreements about utilization management of covered care. You’re free to advocate on behalf of members within the utilization management process.
Value-based programs
Our value-based provider partnership program seeks to create a collaborative relationship that achieves improved clinical, quality and financial outcomes, and enhances the life of every member we touch. We help our providers succeed through a strategic and highly personalized approach that improves the health outcomes of our members — your patients.
Download our value-based program manual, which has all you need to know about how it works.
HEDIS®
HEDIS stands for Healthcare Effectiveness Data and Information Set. Health plans use HEDIS scores to monitor performance in areas like quality of care, access to care and member satisfaction.
Share your voice
Share your voice
Are you a network provider? We’d love to have your input and feedback. Just call 1-855-232-3596 (TTY: 711) for info about joining a committee. You can also get a written copy of the quality program description.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).