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General news and FAQ
September 2024
Requesting a Peer to Peer Review (PDF)
March 2024
Fluoride Varnish Training Requirement Reminder (PDF)
August 2023
Help ensure your patients don’t lose their coverage (PDF)
Past updates
July 2023
Maternity Delivery Billing Reminder (PDF)
April 2023
New EFT/ERA Registration Process (PDF)
March 2023
Member ID Numbers are Changing May 1, 2023 (PDF)
December 2021
Availity to Replace Provider Portal in February (PDF)
August 2021
Complaints, Grievance and Appeal address change (PDF)
April 2021
Availity Portal Now Available (PDF)
November 2020
Aetna Better Health has moved - Get our new address (PDF)
Statewide Preferred Drug List (PDL) FAQ (PDF)
Rapid Acting Insulin Change/Conversion ChartQ (PDF)
FAQ- CHC Eligible Members in a Skilled Nursing Facility (PDF)
SKYGEN USA announced as new Dental Benefits Manager (PDF)
Complaints Grievance & Appeals Updates July 2018 (PDF)
Pharmacy Electronic Prior Authorization (ePA) Notice (PDF)
HEDIS Training Webinar Series (PDF)
Online Provider Enrollment Application for CHIP Providers now Available (PDF)
URGENT DHS Training Announcement (PDF)
Enhancement to secure provider web portal (PDF)
2024 updates
October 2024: Interprofessional Consultation Services (PDF)
October 2024: Aetna and Quest Analytics Partnership (PDF)
September 2024: MAB SARS Administration Fee (PDF)
February 2024: Date of death recovery (PDF)
February 2024: Pharmacist Billing (PDF)
February 2024: Prior authorization of Opioid use disorder (PDF)
February 2024: Updates to the PROMISe provider handbook (PDF)
February 2024 Pharmacist Enrollment Medical Assistance Program (PDF)
February 2024 Doula Enrollment in the Medical Assistance Program (PDF)
February 2024 Medical Assistance Program Vaccine Desk Reference (PDF)
February 2024 Pasteurized Donor Human Milk Coverage Updates (PDF)
Prior auth changes for CPT codes (PDF)
October 2024 Coding Policy Updates (PDF)
Fee Schedule for SARS Administration (PDF)
Genetic Testing Code Updates (PDF)
September Coding Changes (PDF)
510 Coding Policy Change Oct 1 (PDF)
542 Coding Policy Changes Oct 1 (PDF)
Coding policy changes effective June 1 (PDF)
Coding policy changes effective June 1 (PDF)
Radiology Prior Auth Changes (PDF)
January 2024 Coding Policy Changes 3 (PDF)
January 2024 Coding Changes 2 (PDF)
2023 updates
January 5, 2023: Reinstatement of MA Provider Enrollment Requirements (PDF)
November 2023: Upcoming Coding changes 1/1/24 (PDF)
October 2023: Genetic Testing Prior Auth Changes (PDF)
October 2023: Claims policy edit update (PDF)
September 2023: Cardiac Codes Removal (PDF)
September 2023: Enhanced Member Benefit - Sports Physical Coding (PDF)
August 2023: Change in Prior Auth Requirements (PDF)
July 2023: Monovalent COVID-19 vaccine code (PDF)
July 2023: Facility Outpatient Fee Schedule (PDF)
March 2023: June 1 Cotiviti Policy updates (PDF)
February 2023: Coding and Policy Changes (PDF)
2022 updates
Policies and procedures from the Pennsylvania Department of Human Services:
November 2022
COVID-19 Vaccine Counseling Only Under Age 21 (PDF)
COVID 19 Cost Sharing in CHIP (PDF)
COVID-19 Oral Antiviral Enrollment Form 09-26-22 (PDF)
June 2022
Teledentistry Guidelines and Dental Fee Schedule Updates (PDF)
May 2022
Updates to Guidelines for the Delivery of Physical Health Services via Telemedicine (PDF)
April 2022
Age Limits for Payment for Administration of the Flucelvax® Quadrivalent Vaccine (PDF)
Fee Schedule for Personal Care Services (PDF)
Extension of Postpartum Coverage from 60 days to 12 Months (PDF)
March 2022
T1019 Code Additions to MA Fee Schedule for PCS (PDF)
MenQuadfi® and Vaxelis® Vaccines MAB (PDF)
January 2022
Updated Billing Procedures for CRNPs and PAs (PDF)
Vaccine Administration by Pharmacists (PDF)
October 2022
August 2022
New Implementation Client/Coding Validation (PDF)
July 2022
Coordination of Benefits Dental Addition (PDF)
June 2022
CHIP Pre Cert Optimization (PDF)
April 2022
Change In Prior Auth_PCS_T1019 (PDF)
January 2022
2021 updates
Policies and procedures from the Pennsylvania Department of Human Services:
November 2021
Updated Error Codes for Personal Care Services Subject to EVV (PDF)
Naloxone Distribution by FQHC/RHCs (PDF)
October 2021
Expansion of Telemedicine (PDF)
September 2021
Third dose of Sars-Cov-2 vaccine manufactured by Pfizer/Moderna (PDF)
Home Accessibility DME Procedure for obtaining 1150 waiver (PDF)
May 2021
Reinstatement of Prior Authorization Requirements for Certain Services (PDF)
March 2021
Restoration of Provider Revalidation Requirements (PDF)
January 2021
2020 Recommended Child and Adolescent Immunization Schedule (PDF)
September 2021
Sterilization Code update (PDF)
Coordination of Benefits – Secondary insurance requests (PDF)
July 2021
Ultrasound prior auth change (PDF)
June 2021
Prior Auth Reinstatement Update (PDF)
May 2021
April 2021
Coding Policy Update – Electrophysiology (PDF)
February 2021
J Code Prior Auth Changes (PDF)
January 2021
2020 updates
Policies and procedures from the Pennsylvania Department of Human Services:
June 2020
Implementation of Electronic Visit Verification (PDF)
May 2020
EPSDT Program Periodicity Schedule (PDF)
Updates to Childhood Nutrition and Weight Management Services (PDF)
December 2020
340B Drug Pricing Requirements and Billing Instructions (PDF)
October 2020
Avoid Duplicate Rejections on DME, HHC & Hospice Services (PDF)
Billing Requirements – Rendering/Referring NPI (PDF)
Refunding of Provider Overpayments (PDF)
April 2020
Avoid Duplicate Claims for PT/OT on UB Submissions (PDF)
February 2020
Submission of all Encounter Data
APR DRG Version 37 Update (PDF)
PROMISe ID service location requirement reminder (PDF)
January 2020
November 2020
Inpatient Stay Readmission Policy
October 2020
June 2020
Prior Authorization Coding Changes
April 2020
April 2020: Unlisted CPT and HCPCS Codes
March 2020
Evaluation & Management (E&M) Code Billing Update
February 2020
Eviti Connect Oncology Decision Support - REVISED
National Drug Code (NDC) Validation Requirements
January 2020
Archived updates
Important update: June 16, 2016
The Commonwealth of Pennsylvania’s Department of Human Services (DHS) intends to enforce the Provider Enrollment and Screening Provisions of the Affordable Care Act (ACA) (§ 455.414).
We want to make all providers aware that DHS enforcement of the provider enrollment and revalidation requirement will begin on August 28, 2017.
Please ensure you have met all enrollment requirements, including revalidation of your PROMISEe ID, to avoid termination from the Aetna Better Health of Pennsylvania network.
Read the full provider notice (PDF) for helpful revalidation information that was previously sent to all providers earlier this year.
On January 15, 2009, the US Department of Health & Human Services issued two final rules for adoption:
- An updated HIPAA X12 standard version 5010 for electronic transactions, with a compliance date of January 1, 2012. The updated format has more than 1,300 changes to the 4010 standard (with 600+ just for claims).
- Adoption of the ICD-10 Code Sets with a compliance date in October 2015 (version 5010 accommodates the ICD-10 code structure; 4010 does not).
Aetna Better Health met the compliance requirements for the federally mandated HIPAA 5010 version transactions for 1/1/2012 and is on track to be able to accept ICD-10-CM & PCS Codes for dates of service for October 2015.
Online ICD-10 resources
- Crosswalks for the Top 50 Codes by Specialty at the AAPC website
- 100 Tips for ICD-10-PCS Coding (PDF)
- Free code conversion tool
- Quick tips for qualifiers (PDF) from Pennsylvania's Department of Human Services (DHS)
The Medicaid Electronic Health Records Incentive Payment Program was created by the American Reinvestment and Recovery Act and administered by Centers for Medicare & Medicaid Services. This program provides funding to states to develop and administer provider incentive programs.
On August 20, 2015, Governor Tom Wolf announced that all CHIP health insurance plans would provide enhanced benefits. The added benefits are outlined in the Affordable Care Act. These benefits take effect for all children enrolled in CHIP on December 1, 2015.
These changes include removing some historical benefit limits on specific services to ensure Minimal Essential Coverage (MEC) compliance for all CHIP products.
Some categorical benefit changes include:
- Increasing vision services to include low vision items and “add-on” services such as protective coating, when medically necessary
- Adding sealants to the dental benefit package
- Ensuring parity in the number of behavioral health visits without limit
- Increasing outpatient rehabilitation visit limits to 30 per modality per benefit year (PT, OT, ST)
- Removal of dollar limits for autism services
- Coverage for a home health visit when discharged from the hospital for a delivery or mastectomy
There is nothing current CHIP members need to do to get these benefits. All CHIP members will automatically receive these enhanced health benefits. Members will not receive new ID cards as the benefits are now MEC-required for all Free, Low and Full Cost CHIP products by all CHIP contractors in the Commonwealth of Pennsylvania.
We are pleased to inform you that your Quality Measurement Reports are now available online. You may now access year-to-date reports through the Provider Reports Management Tool on our secure web portal.
Some examples of the types of reports you can access include:
- HEDIS Gaps-in-Care Reports
- Pay-for-Performance Measure Reports
These reports serve as a guide for which Aetna Better Health members need care and where your practice stands regarding Pay-for-Quality incentives for the care you provide. Be sure you receive credit for the care you provide to Aetna Better Health members. Pay-for-Quality is awarded for care captured administratively through claims submissions.
If you have provided care that we may not have captured due to potential claims or coding issues, please contact Aetna Better Health Provider Relations at 1-866-638-1232, option 3. You can also directly contact the Quality Translator that has been sending you Gaps-in-Care Reports for assistance.
As a reminder, you can access up-to-date panel lists for your practices on our secure web portal. You can also upload Medical Records for HEDIS Medical Record Review.
Effective November 1, 2016, Aetna Better Health will apply our Emergency Department (ED) claims review policy to Medical Assistance and CHIP claims.