It’s been a hard summer with all the Aetna / TRIAD confusion. Providers have been complaining about the administrative nightmares for months, not to mention being financially stressed by the delays in receiving payment. The changes made to the Aetna / TRIAD relationship included a new authorization process and a new fee schedule, as well as the inclusion of Aetna PPO policies into those managed by TRIAD. There has been mass confusion as to how these changes affect providers and it is further complicated because Aetna and TRIAD did not seem equipped to administer these changes when they occurred on 6/1/12. Although it is still a very fluid situation, CB&C can tell you what we know at this point.
Participation Status: Prior to May 2012, there were providers that were out of network with BOTH Aetna and TRIAD, and then there were providers that were participating with Aetna, but NOT with TRIAD. And then there were providers that were already participating with BOTH Aetna and TRIAD. It is important to know which category you were in PRIOR to May and it is even more important to know where you fall AFTER June 2012. If you don’t know, you must contact BOTH Aetna and TRIAD and obtain this information.
I would suggest you have them verify all the ‘numbers’ that are relative to your practice. Provide them with your personal NPI and also your facility NPI (if applicable). Give them your tax ID# or SS# as well. You need to know this information to effectively know where to submit claims and understand the authorization requirements.
Claim Submission: If you are non participating with Aetna and TRIAD, you really should just send all your claims to Aetna right now (if there are claims that are to be paid by TRIAD, Aetna will forward your claims for you). It is the same for those of you that are participating with Aetna but NOT TRIAD—send claims to Aetna and they will forward to TRIAD if necessary. For providers that are participating with TRIAD, your verification really needs to be done properly to find out where claims are to be sent. You should call TRIAD and give them the patient’s ID#. They can look up the patient and direct you as to whether they are responsible to handle claims processing or not. If TRIAD doesn’t have the answer immediately, they have been diligent in researching the problem and calling the provider back within 24 hours.
Authorization Requirements: If non participating with Aetna and TRIAD or if you are still currently participating with Aetna only —you generally do not have to fulfill or complete any type of treatment plan / pre-cert requirements. However, they could (and probably will) ask the provider to support medical necessity and request clinical documentation for review. If you are participating with TRIAD, you will have to complete any authorization requirements for that patient’s policy. As of 6/1/12, the paperwork the providers are required to complete has changed. There is now a ‘Physical Medicine Authorization’ form that needs to be completed. In addition, time frames for when this paperwork has to be completed has also changed. Under the new TRIAD guidelines, the provider may not have to submit the authorization paperwork until after the 10th visit (but before the 11th). This is referred to as the ‘10 visit waiver’. Just as we suggested that if you were participating with TRIAD you inquire upon verification whether they are responsible to receive and process claims, you should also inquire about authorization requirements. Due to the confusion, we suggest that if the policy is managed by TRIAD, you give them information about the patient (are they a new patient or a returning patient, etc), and ask them SPECIFICALLY when you should submit the authorization paperwork. Get a reference # from them and make sure the information in that reference # is specific to your questions. It is also important to note that there are Aetna insured employer groups who have opted out of TRIAD either managing the claims payment OR managing the authorization or BOTH. This will actually give you the claim submission guidelines by provider class, and if you scroll down the webpage to the Utilization Management section, you will notice additional links to different classifications of excluded employer groups.
Fee schedule: Although there is still a fee schedule per CPT code, TRIAD participating providers will now be reimbursed a Maximum Daily Allowed Amount per day. There are different daily maximums for PPO policies and HMO policies. In addition, the maximum daily amount changes if an exam was performed. In addition, there is a $3 administration fee that will also be deducted from the providers PPO payments. To view this information, please visit our website at www.CBCbilling.com or contact TRIAD healthcare directly.
