Table of contents
Introduction ...........................................................................................................................................................3
Our programs.........................................................................................................................................................4
Clinical delivery .....................................................................................................................................................7
Quality programs ................................................................................................................................................ 15
Working electronically with us...........................................................................................................................22
Appendix A: Aetna® Behavioral Health treatment record review criteria and best practices ................. 24
This Behavioral Health Provider Manual, the EAP Manual and other related communications are posted on Aetna.com,
on the Provider Education & Manuals page.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of
companies (Aetna). Aetna Behavioral Health refers to an internal business unit of Aetna.
2
Introduction
Welcome to the Aetna® Behavioral Health network
Our behavioral health programs focus on the important role of mental health on a person’s overall well-being.
We’ll give you valuable tools to help you work with us and provide quality service to our members. This manual
is an extension of your contract with us. All practitioners and facilities must abide by the conditions set forth in
your contract and in our provider manuals.
Our guiding principles
Our behavioral health programs support our belief
in the following:
• Enhancing our members’ — your patients’ —
clinical experiences
• Adhering to the importance of the mind-body
principle and connection
• Providing a treatment approach that is
evidence-based, goal-directed, and consistent with
accepted standards of care, all Aetna Clinical Policy
Bulletins, and Aetna clinical practice guidelines
• Providing treatment that is medically necessary
• Educating members about the risks and benefits of
available treatment options
• Developing a strong relationship with you,
informing you about resources, and concentrating
on continuity of care among all, for the benefit of
you and your patients
• Integrating behavioral health care across our
product spectrum
What you’ll find in this manual
We developed this manual with you in mind — giving you
what you need to work with us and make administration
easier. This manual contains information about:
• Network participation
• Condition management programs
• Telemedicine
• Credentialing/recredentialing
• Site visits and monitoring
• Contact information/how to reach us
• Clinical practice guidelines
• Authorization and referral processes
• Member and provider denials and appeals
• Case management
• Quality programs
• Working with us electronically, and much more
How to reach us
Our medical directors and staff are available to speak
with you about utilization management issues. They’re
available, during and after business hours, via toll-free
telephone numbers. Behavioral health medical directors
make all final coverage* denial determinations involving
clinical issues.
If a treating provider doesn’t agree with a decision about
coverage or wants to discuss an individual member’s
case, Aetna Behavioral Health staff are available 24 hours
a day, 7 days a week. Behavioral health care providers
can contact staff during normal business hours
(8 AM to 5 PM, Monday through Friday)** by calling the
toll-free precertification number on the member’s ID
card. When only a Member Services number is shown
on the card, you’ll be directed to the Precertification unit
through either a phone prompt or a Member Services
representative.
On weekends, company holidays, and after normal
business hours, members and providers can use these
same toll-free phone numbers to contact our staff.
Our staff identify themselves by name, title and
organization when they initiate or return calls about
utilization management issues. We also offer TDD/TTY
services for deaf, hard-of-hearing, or speech-impaired
members, and language assistance for members to
discuss these issues.
*For these purposes, “coverage” means either the determination of (i) whether or not the particular service or
treatment is a covered benefit under the terms of the particular member’s benefits plan, or (ii) where a physician or
health care professional is required to comply with the Aetna patient management programs, whether or not the
particular service or treatment is payable under the terms of the provider agreement.
**All continental U.S. time zones; hours of operation may differ based on state regulations. In Texas: 6 AM to 6 PM CT
(Monday through Friday) and 9 AM to noon CT on weekends and legal holidays. Phone recording systems are in use
during all other times.
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Our programs
Behavioral Health Condition
Management program
We offer a case management program that supports
patients’ medical and psychological needs. Our focus is
on helping our members make the best use of their
benefits by coordinating behavioral health and wellness
services. To support the efforts of clinicians, we also
closely follow patient progress and treatment
recommendation adherence and share it with you.
Through this program, we:
• Work with your practice and other health care
professionals on patient progress
• Evaluate patient needs to promote full use of
covered services and benefits in support of your
treatment plan
• Provide educational materials and decision-support
tools, both online and via mail, so patients better
understand their illness
• Use case management by phone to support patient
adherence to your treatment plan
This program provides additional care options for your
eligible Aetna® patients.
Who may benefit from our Behavioral Health
Member Support program
• Aetna members (children, adolescents and adults):
- With co-occurring medical and behavioral
health conditions
- With complex behavioral health conditions who
have had inpatient readmissions, extended
hospitalization stays, or suicide attempts resulting
in medical admissions
• Aetna members ages 14 and older:
- Who have symptoms of major depression,
dysthymia, depression not otherwise specified, or
bipolar depression
- Who are diagnosed with anxiety disorders, such as
generalized anxiety, panic disorder, or post-traumatic
stress syndrome
• Aetna members ages 18 and older who have an alcohol
problem, including alcohol dependence or a more
severe alcohol use disorder
Members who complete this program show significant
symptom relief and improvement in overall health.
To learn more about the Aetna Behavioral Health
Member Support program, call us at
1-800-424-4660 (TTY: 711).
Our Provider Network
We’ve developed a spectrum of behavioral health
services for our members. In doing so, we contract with
licensed psychiatrists, psychologists, social workers and
other master’s-prepared clinicians. Among these
practitioners, numerous clinical, linguistic, and cultural
specialties are represented to serve individual member
and geographic needs. Our goal is to create a
collaborative relationship with the behavioral health
care professional community. We believe that the key
to quality care and member satisfaction is a diverse,
well-informed, quality network. To accomplish this, we
credential clinicians who are independently licensed and
well trained in their particular area of expertise.
Credentialing and recredentialing
A behavioral health care professional must be
credentialed by us before joining the behavioral
health network.
We use a standard application and a common database
through the Council for Affordable Quality Healthcare
(CAQH®) to gather credentialing information.
Our recredentialing process
We reassess a provider’s qualifications, practice and
performance history every three years, depending on
state and federal regulations and accrediting agency
standards. This process is seamless to providers who are
due for recredentialing and whose applications are
complete within the CAQH database.
We’ll send providers (whose applications aren’t complete
within the CAQH database) three reminder letters. The
letters will ask them to update their recredentialing data.
If they don’t respond to the letters, we’ll call them.
How can I check the status of my
recredentialing application?
Call our Credentialing Customer Service department
at 1-800-353-1232 (TTY: 711).
Just go to the “Request participation“ section of our
website to start the application process.
4
The minimum criteria to become a credentialed Aetna®
behavioral health care professional are:
• Graduation from an accredited professional school
applicable to the applicant’s degree, discipline
and licensure
• For physicians, completion of residency training in
psychiatry and board certification, unless the
physician meets the conditions delineated in our
board certification exception policy; a medical
director reviews exceptions to the board
certification requirement
• Malpractice insurance in amounts specified in the
Aetna agreement
• Availability for emergencies by mobile device or other
established procedures that we deem acceptable
• Submission of an application containing all applicable
attestations, necessary documentation and signatures
• If applicant is a physician addictionologist, certification
by the American Society of Addiction Medicine (ASAM)
• Current, unrestricted license
• The absence of current debarment or suspension from
state or federal programs
Open the door to electronic communications
Our electronic correspondence option allows your office
to get information from us online instead of on paper.
Read the OfficeLink Updates™ provider newsletter and
other time-sensitive correspondence online. We’ll send
you an email when the newsletter or other
communications are ready to view.
Site visits and monitoring
We make office site visits to network practitioners after
getting a member’s complaint. We evaluate the physical
accessibility, physical appearance, and adequacy of
waiting and exam room space related to the settings
in which member care is given.
We set standards for office site criteria and medical
record-keeping practices. If a site visit is required for
member complaints to evaluate the physical accessibility,
physical appearance, or adequacy of waiting and exam
room space, we also review the medical record-keeping
practices. We assess methods used for keeping
confidentiality of member information. We also assess
methods for keeping information in a consistent,
organized manner for ready accessibility.
No site visit is required for complaints about availability or
medical record keeping. The office assessment criteria
are stated in the practitioner agreements and business
criteria of the practitioner agreements. The medical
record-keeping practice standards are stated in the
medical record criteria that we distribute to practitioners.
Also see Appendix A on page 24 for more information.
Notification of status changes
Federal provider directory regulations require Aetna and
providers to work together to maintain accurate provider
directory lists. It is important for you and Aetna to keep
your information current and to periodically confirm its
accuracy every ninety (90) days, as well as upon request.
Behavioral health care professionals are required to
notify us in writing within 14 days of any changes
related to the following circumstances:
• Change in professional liability insurance
• Change of practice location, billing location,
telephone number or fax number
• Status change of professional licensure, such as
suspension, restriction, revocation, probation,
termination, reprimand, inactive status or any
other adverse situation
• Change in tax ID number used for claims filing
• Malpractice event, as described in the “Compliance
with Policies” section of the health care professional
contract (provider or specialist agreement)
Note:
Providers who previously practiced only under
a group and are now starting a solo practice
require an individual contract.
Please fax correspondence about changes to
859-455-8650.
Questions?
• General: call our Provider Service Center, which is
available from 8 AM to 5 PM.
• Health maintenance organization (HMO)-based and
Aetna Medicare Advantage plans: call
1-800-624-0756 (TTY: 711).
• All other plans: call 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711), or visit Availity.com, our
provider portal.
Update your office’s contact
information online
If you need to change or update your office’s contact
information (new email, mailing address, phone/fax numbers),
go to Availity.com and access our provider portal.
Having your correct email address on file is very
important to us. It’s our preferred and efficient way
of communicating important information to you.
5
Behavioral health care provider access-to-care standards*
Service Time frame
Non-life-threatening
emergency needs
Within 6 hours of request
Urgent needs Within 48 hours of request
Routine office visits Initial visit within 10 business days of request
Follow-up visits should be available within 5 weeks for behavioral health
practitioners who prescribe medications, and within 3 weeks for
behavioral health practitioners who don’t prescribe medications.
Following emergency department
visit for behavioral health condition
or alcohol or other drug abuse or
dependence
Within 7 days of emergency department visit
Following hospital discharge for a
behavioral health condition
Within 7 days of the inpatient discharge date
After-hours and emergency care Each behavioral health practitioner must have a reliable 24 hours a day,
7 days a week live answering service or voicemail message.
• MDs must have a notification system or designated
practitioner backup.
• Non-MDs, at a minimum, must have a message system that provides
24-hour contact information to a licensed professional.
Online security is more important than ever in today’s
high-tech world. Our provider portal lets you validate the
information you submit. It also ensures that unauthorized
individuals aren’t submitting incorrect information about
your office or facility. Your security officer can make
changes to your information, or they may give access
to others.
You’ll need to register for our provider portal
To use the provider portal, you must first register.
And it’s easy! Then, you’ll also be able to submit claims
transactions, check member eligibility and benefits,
and verify referrals.
*More stringent state requirements supersede these accessibility standards.
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Clinical delivery
Access to care
Members may access behavioral health care in
three ways:
1. Through direct access to the behavioral
health provider
2. Through a recommendation from the primary care
physician or other treatment provider
3. Through a referral from an employee assistance or
student assistance program provider
For a list of services that require precertification and
concurrent review, go to AetnaElectronicPrecert.com
and click “Check our precertification lists.” To request
precertification, use our provider portal at Availity.com or
any other website that allows you to send precertification
requests electronically. (You can register at Availity.com
for our provider portal via Availity®.) You may also use the
toll-free behavioral health telephone number on the
member’s ID card. For Open Choice® and Traditional
Choice® plan members, use the toll-free Member
Services telephone number on the member’s ID card.
These numbers are accessible 24 hours a day, 7 days a
week. A screening process to determine the urgency of
the need for treatment may occur at the time of the call.
Authorization and precertification process
Authorization/precertification is the process of
determining the eligibility for coverage of the proposed
level of care and place of service.* To ensure Aetna®
members receive the highest quality of care, a
comprehensive diagnostic evaluation prior to the
initiation of treatment is expected. Diagnoses submitted
on claims must be current and consistent with the most
recent Diagnostic and Statistical Manual of Mental
Disorders (DSM) criteria. Collecting complete and
accurate clinical data is critical to successfully
completing the authorization process. Treatment
approach is expected to be evidence based, goal
directed, and consistent with accepted standards of
care, Aetna Clinical Policy Bulletins and Aetna clinical
practice guidelines.
It is also expected that treatment provided is medically
necessary: “Medically necessary services are those
health care services that a practitioner, exercising
prudent clinical judgment, would provide to a patient for
the purpose of preventing, evaluating, diagnosing or
treating an illness, injury, disease or its symptoms, and
that are (a) in accordance with generally accepted
standards of medical practice; (b) clinically appropriate,
in terms of type, frequency, extent, site and duration, and
considered effective for the patient’s illness, injury or
disease; (c) not primarily for the convenience of the
patient, physician or other health care provider; and (d)
not more costly than an alternative service or sequence
of services at least as likely to produce equivalent
therapeutic or diagnostic results as to the diagnosis or
treatment of that patient’s illness, injury or disease. For
these purposes, ‘generally accepted standards of care’
means standards that are based on credible scientific
evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community,
or otherwise consistent with physician specialty society
recommendations and the views of physicians practicing
in relevant clinical areas and any other relevant factors.”
Some employers have specific preauthorization
requirements for their employees, so always check
with our Provider Service Center at 1-800-624-0756
(TTY: 711) for HMO and Medicare Advantage plans and
1-888-MDAetna (1-888-632-3862) (TTY: 711) for
all other plans.
• All inpatient behavioral health services must be
precertified and are managed through a concurrent or
retrospective review process.
Intermediate levels of care, such as residential treatment,
and partial hospitalization also require precertification.
For more information, go to AetnaElectronicPrecert.com
and click “Check our precertification lists.”
Exceptions:
*Precertification is the process of collecting information before inpatient admissions and selected ambulatory procedures
and services for the purpose of (1) receiving notification of a planned service or supply, or (2) making a coverage
determination. It doesn’t mean precertification as defined by Texas law as a reliable representation of payment.
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This policy applies to all Aetna® plans with the exception
of behavioral health benefits that we administer but don’t
manage and self-funded plans with plan sponsors that
have expressly purchased precertification requirements.
In addition to reviewing clinical information to determine
coverage, our utilization management clinician will
discuss treatment alternatives, the appropriate level of
care and explore discharge planning opportunities. If
Aetna case management is involved, we will request that
the member’s family, physician(s), and other health care
professionals be involved in the treatment plan and
activities. We recommend that you discuss the available
benefits for outpatient care with your patient, so that
treatment can be planned accordingly.
You can submit a precertification request in one of
three ways:
1. Through Availity.com (our provider portal)
2. Through one of our vendors — go to
Aetna.com/provider/vendor to see our list
3. By calling our Provider Service Center at
1-800-624-0756 (TTY: 711)
Learn more.
Note:
Stepping down to a less restrictive level of care within the
same facility (for example, a step down from inpatient
detoxification to inpatient rehabilitation), even within the
same unit of the same facility, requires precertification.
At times, a member may seek treatment outside of our
network (for example, a nonparticipating referral for
routine outpatient behavioral health services). This is a
written or verbal request that we review. Reasons that a
nonparticipating referral may be approved include:
• When a specific health care professional preferred
by the member isn’t available in network (and the
member’s plan provides coverage for
out-of-network services)
• When the member is continuing, or returning to,
treatment with a nonparticipating health care
professional, in certain circumstances
• When the primary care practitioner identifies a local or
known nonparticipating health care professional with
expertise in the treatment of the member’s condition
(and the member’s plan provides coverage for
out-of-network services)
More about precertification of behavioral
health services
It’s important to note that outpatient care that isn’t
consistent with evidence-based, goal-directed practices,
Aetna Clinical Policy Bulletins and Aetna clinical practice
guidelines may be subject to quality-of-care and
utilization reviews.
Also note that outpatient care inconsistent with
such a treatment approach may be subject to a
concurrent review.
It’s expected that facility diagnostic evaluations assess
for either comorbid chemical dependency or comorbid
psychiatric conditions that could be impacting
current presentation.
Go to Aetna.com for more information on
services requiring precertification and
electronic precertification.
A complete list of behavioral health services requiring
authorization and precertification is available at
Aetna.com in the “For Providers” section. Some
employers have specific precertification requirements for
their employees. To verify outpatient precertification
requirements for a specific member’s plan, contact our
Provider Service Center.
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Precertification for ABA
Applied behavior analysis (ABA) services require
precertification. To get ABA services precertified, call the
number on the member’s Aetna® ID card and speak to a
Member Services representative.
You can access our medical necessity guidelines for
ABA here. We’ve used the American Medical Association
Category I CPT codes (97151–97158) for Adaptive
Behavior Treatment as of January 1, 2019, and
Category III CPT codes (0362T and 0373T).
Coverage determinations and utilization
management (UM)
We use evidence-based clinical guidelines from
nationally recognized authorities to make UM decisions.
We base decisions on the appropriateness of care and
service. We review coverage requests to determine if the
requested service is a covered benefit under the terms of
the member’s plan and is being delivered consistently
with established guidelines. Aetna offers providers an
opportunity to present additional information and discuss
their cases with a peer-to-peer reviewer as part of the
utilization review coverage determination process. The
timing of the review incorporates state, federal, Centers
for Medicare and Medicaid Services (CMS) and National
Committee for Quality Assurance (NCQA) requirements.
If we deny a request for coverage, the member (or a
physician acting on the member’s behalf) may appeal
this decision through the complaint and appeal process.
Depending on the specific circumstances, the appeal
may be made to a government agency, the plan sponsor,
or an external utilization review organization that uses
independent physician reviewers, as applicable.
We don’t reward physicians or other individuals who
conduct utilization reviews in order to issue denials of
coverage or create barriers to care or service. Financial
incentives for utilization management decision makers
don’t encourage denials of coverage or service. Rather,
we encourage the delivery of appropriate health care
services. In addition, we train utilization review staff to
focus on the risks of underutilization and overutilization
of services. We don’t encourage utilization-related
decisions that result in underutilization.
Learn more
Our medical directors are available 24 hours a day for
specific utilization management issues. Contact us by:
• Visiting our website
• Calling us at 1-800-624-0756 (TTY: 711)
• Calling Patient Management staff using the
Member Services number on the member’s ID card
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How we determine coverage
Our medical directors make all coverage decisions that
involve clinical issues. Only licensed medical directors,
psychiatrists/psychologists and pharmacists make denial
decisions for reasons related to medical necessity.
(Licensed pharmacists and psychologists review
coverage requests, as permitted by state regulations.)
Where state law mandates, utilization review coverage
denials are made, as applicable, by a physician or a
pharmacist who is licensed to practice in that state.
Patient Management staff use evidenced-based clinical
guidelines from nationally recognized authorities to guide
utilization management decisions involving
precertification, inpatient review, discharge planning and
retrospective review. Staff use the following criteria as
guides in making coverage determinations, which are
based on information about the specific member’s
clinical condition.
1. Level of Care Utilization System:*
The Level of Care Utilization System for Psychiatric
and Addiction Services, or LOCUS, is a nationally
recognized level of care tool used to help determine
the resource intensity needs of individuals who receive
adult mental health services. It is used for patients
18 years and older who are in need of placement in
specialized psychiatric or mental health facilities or
units. This person-centered approach aims to find the
best fit between individual needs and behavioral health
services. For more information about LOCUS, visit the
American Association of Community Psychiatry
(AACP) website at CommunityPsychiatry.org.
The Child and Adolescent Level of Care/Service
Intensity Utilization System and Child and Adolescent
Service Intensity Instrument, or CALOCUS-CASII,
are nationally recognized tools used to determine
the appropriate level of care placement for a child
or adolescent. These tools are used for children and
adolescents from 6 to 17 years of age. For more
information about these tools, visit the American
Academy of Child and Adolescent Psychiatry
(AACAP) website at AACAP.org.
2. The ASAM Criteria: Treatment Criteria for
Addictive, Substance-Related and
Co-Occurring Conditions
This is a nationally recognized criteria set that helps
determine appropriate levels and types of care for
patients in need of evaluation and treatment for
chemical dependency and substance abuse
conditions and diagnoses. The third edition is
compliant with the DSM-5 and also applies for
patients who are in need of placement in specialized
chemical dependency detoxification or rehabilitation
facilities or units.
Note:
We supply relevant pages of ASAM’s criteria upon
request. Please call us by any of the ways below to
submit a request.
• Provider Service Center: 1-800-624-0756
(TTY: 711)
• HMO and Aetna® Medicare Advantage plans:
1-800-624-0756 (TTY: 711)
• All other plans: 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
3. State-specific criteria
The Level of Care for Alcohol and Drug Treatment
Referral (LOCADTR) is used for chemical dependency
treatment that takes place in New York. They are
available online.
Our Applied Behavior Analysis (ABA) Medical
Necessity Guide
The ABA Medical Necessity Guide is a clinical
behavioral health patient-management instrument
used to guide and track treatment decisions for our
members in need of ABA. For practitioners treating
autism spectrum disorders using ABA, either national
certification is needed from the Behavior Analyst
Certification Board (BACB), or the practitioner must be
licensed as a behavior analyst in the state in which
they practice.
4. Aetna Clinical Policy Bulletins (CPBs)
These are based on evidence in peer-reviewed,
published medical literature; technology assessments
and structured evidence reviews; evidence-based
consensus statements; expert opinions of health care
providers; and evidence-based guidelines from
nationally recognized professional health care
organizations and government public health agencies.
CPBs are detailed technical documents that explain
how we make coverage decisions for members under
our health benefits plans. They spell out what medical,
dental, pharmacy and behavioral health technologies
and services may, or may not, be covered.
You can learn more about these guidelines on
our website.
Participating practitioners can ask for a hard copy of the
criteria we used to make a determination. Just call us at
1-888-632-3862 (TTY: 711).
* The LOCUS and CALOCUS/CASII are instruments that an Aetna clinician uses to aid in the decision-making process.
They help determine the level of care appropriate for effective treatment for a mental health patient. “Aetna clinician”
may mean a care manager, an independent physician reviewer working on our behalf or an Aetna medical director.
LOCUS and CALOCUS/CASII guidelines don’t constitute medical advice. Treating providers are solely responsible for
medical advice and treatment of members.
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Both new and revised CPB drafts undergo a
comprehensive review process that includes review by
our Clinical Policy Council. Our chief medical officer (or
designee) approves CPBs. The Aetna® Clinical Policy
Council evaluates the safety, effectiveness, and
appropriateness of medical technologies (that is, drugs,
devices, medical and surgical procedures used in
medical care, and the organizational and supportive
systems within which such care is provided) that are
covered under our medical plans, or that may be eligible
for coverage under our medical plans.
In making this determination, the Clinical Policy Council
reviews and evaluates evidence in the peer-reviewed,
published medical literature; information from the U.S.
Food and Drug Administration and other federal public
health agencies; evidence-based guidelines from
national medical professional organizations; and
evidence-based evaluations by consensus panels and
technology evaluation bodies.
The criteria noted above are only guidelines. Their use
doesn’t preclude the requirement that trained, licensed,
credentialed and experienced behavioral health
professionals must exercise their independent
professional judgment when providing behavioral health
care services to our members.
Referrals for evaluation and/or treatment of chemical
dependency and mental health issues will be reviewed
by a psychiatrist or licensed clinician to determine the
appropriate level of care.
For current information on our medical necessity criteria
or Clinical Policy Bulletins, visit Aetna.com/health-
care-professionals/clinical-policy-bulletins.html for
our Clinical Policy Bulletins page.
If you need hard copies of any of Aetna Behavioral Health
utilization management criteria or CPBs, call us at
1-888-632-3862 (TTY: 711).
Some states have specific requirements or laws in place
for practitioners and facilities. For more information on
state-specific requirements, see our public website.
Clinical practice guidelines (CPGs)
Consult behavioral health CPGs as you care
for patients
The National Committee for Quality Assurance (NCQA)
requires health plans to regularly inform practitioners
about the availability of CPGs.
The following behavioral health CPGs are based on
nationally recognized recommendations and
peer-reviewed medical literature. We adopt and
encourage the use of CPGs to help practitioners in
screening, assessing and treating common disorders.
Recognized professional practice societies, such as the
American Psychiatric Association and the American
Academy of Pediatrics, publish recommended
guidelines. Before we adopt each guideline, we review
relevant scientific literature and get practitioner input
through our Quality Advisory Committee. Network
practitioner feedback then goes to a National Quality
Oversight Committee for adoption.
Once implemented, we review each guideline at least
annually for continued applicability and update them as
needed. We report guideline changes through our online
newsletter, OfficeLink Updates, posted on the
newsletters page of our public website.
How the guidelines help in clinical decision making
When used in clinical decision making, adherence to
these recognized guidelines helps to ensure that care
authorized for acute and chronic behavioral health
conditions meets national standards for excellence.
We measure adherence through use of the Healthcare
Effectiveness Data and Information Set (HEDIS®) measures.*
Our adopted guidelines are intended to support, not
replace, sound clinical judgment. We welcome your
feedback and will consider all suggestions and
recommendations in our next review. You can
contact our Quality Management department at
QualityImprovement2@Aetna.com.
To support clinical decision making, we provide
all adopted practice guidelines to our behavioral
health staff and distribute them to contracted
network professionals when requested to do so.
*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
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Behavioral health clinical practice guidelines
we currently adopt:
• American Academy of Pediatrics Clinical Practice
Guideline for the Diagnosis, Evaluation, and
Treatment of Attention-Deficit/Hyperactivity
Disorder in Children and Adolescents.
• American Psychiatric Association (APA) Practice
Guideline for the Treatment of Patients with Major
Depressive Disorder
• APA Practice Guideline for the Pharmacological
Treatment of Patients with Alcohol Use Disorder
• APA Practice Guideline for the Treatment of
Patients with Substance Use Disorders
There are several other behavioral health guidelines
to help support your patient care decisions on the
APA website.
For a copy of a specific CPG, call us at 1-888-632-3862
(TTY: 711).
Discharge review
Discharge planning includes all of the following
components:
• If a patient needs to be admitted to a different level of
care, discharge information will be provided to the
health care professional/facility at the time of referral
for admission.
• Facilities will designate a clinical staff member
to be responsible for coordinating discharge
planning activity.
• A written discharge plan must exist for each member,
and discharge planning should begin at the time
of admission.
• Where required, the inpatient facility, partial hospital
program, intensive outpatient program or other
involved health care professional will obtain a release
of information from the member that meets all state
and federal confidentiality regulations. If a release is
obtained, the provider will facilitate coordination of care
and collaboration with the primary care practitioner
and/or other appropriate health care specialist.
• Facilities should arrange for follow-up appointments
within seven days for each member discharged from
an inpatient stay. We also ask that health care
professionals to schedule such appointments
within seven days.
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Continuity and transition of care
We may allow members to continue care for a specified
period of time with a behavioral health care professional
who has left the network. This will ensure that the
member’s course of treatment isn’t interrupted.
The length of time may vary and depends on regulatory
requirements, company policies, and the health care
professional’s willingness to continue to treat the
member. Company policy states that participating
providers leaving the network will work with us to
transition the member to a participating provider when
network benefits are requested and the care will exceed
the 90-day transition period. A health care professional
may not continue to care for a member under the
network benefit if we determine that a quality-of-care
issue may negatively impact the member’s care.
Inpatient level of care
Members who, at the time of enrollment, are being
treated at an inpatient level of care should complete their
single, uninterrupted course of care under the benefits
plan or policy that’s active at the time of admission.
All other levels of care
Patients who have met certain requirements are
allowed to continue an “active course of treatment”
with a nonparticipating practitioner. They can continue
for up to 90 days without penalty, within the benefits
limitations, at the new or preferred plan benefits
level as outlined in the provider contract. In some
states, regulatory requirements may mandate that
we continue coverage beyond 90 days.
Collaboration and coordination of care
We appreciate the importance of the therapeutic
relationship and strongly encourage continuity,
collaboration and coordination of care. Whenever a
transition-of-care plan is required, whether the transition
is to another outpatient provider or to a less intensive
level of care, the transition is designed to allow the
member’s treatment to continue without disruption
whenever possible.
We also believe that collaboration and communication
among providers who are participating in a member’s
health care are essential for the delivery of integrated,
quality care. There are several ways to ensure continuity,
collaboration and coordination of care, including:
• Ambulatory follow-up
Members being discharged from an inpatient stay
should have a follow-up appointment scheduled before
discharge. The appointment should occur within seven
days of discharge.
• Emergency department follow-up
Members seen in an emergency department setting
for a behavioral health condition or for alcohol or other
drug abuse or dependence should have a follow-up
appointment within 7 days of discharge. Emergency
department staff should assist with appointment set-up
if possible. Behavioral health care professionals should
have available appointments within 7 days for
members recently treated in an emergency
department.
• Timely and confidential exchange of information
With written authorization from the member, it’s
important that you communicate key clinical
information in a timely manner to all other health
care providers participating in a member’s care,
including the member’s primary care practitioner.
• Timely access and follow up for medication
evaluation and management
Members should receive timely access and regular
follow-up for medication management.
Behavioral health care professional responsibilities
for all levels of care
• Explain to the member the purpose and importance of
communicating clinical information and coordinating
care with other relevant health care providers treating
the same patient.
• Obtain written authorization from the member to
communicate significant clinical information to other
relevant providers.
• Obtain, at the initial treatment session, the names and
addresses of all relevant health care providers involved
in the member’s care.
• Subject to applicable law, include the following in
the Authorization to Disclose document signed by
the member in both outpatient office and
higher-levels-of-care settings:
- A specific description of the information to
be disclosed
- Name of the individual(s) or entity authorized to make
the disclosure
- Name of the individual(s) or entity to whom the
information may be disclosed
- An expiration date for the authorization
- A statement of the member’s right to revoke the
authorization, any exceptions to the right to revoke
and instructions on how the member may revoke
the authorization
- A disclaimer that the information disclosed may be
subject to re-disclosure by the recipient and may no
longer be protected
- A signature and date line for the member
- If the authorization is signed by the member’s
authorized representative, a description of the
representative’s authority to act for the member
If needed, an acceptable Behavioral Health/Medical
Provider Communication Form is located at
Aetna.com in the “For Providers” section.
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• Contact the member’s primary care practitioner when
a member enters care and promptly when there is an
emergency or, with member consent, under
circumstances such as the following:
- Medical comorbidities and/or medication
interactions are a possibility
- Clinical information needs to be exchanged to aid in
diagnosis and/or treatment
- Primary care practitioner or specialist support for a
treatment plan would enhance member compliance
and/or treatment outcome
- Primary care practitioner or specialist has requested
immediate feedback
• Upon obtaining appropriate authorization,
communicate in writing to the primary care practitioner
or other appropriate specialist, at a minimum, at the
following points in treatment:
- Initial evaluation or assessment
- Significant changes in diagnosis, treatment plan or
clinical status
- When medications are initiated, discontinued or
significantly altered
- Termination of treatment
It’s recommended that communication occur within
two weeks of the above situations.
• Work with medical practitioners to support the
appropriate use of psychotropic drugs.
• Collaborate with our Patient Management staff to
develop and implement discharge plans before the
member is discharged from an inpatient setting.
• Cooperate with follow-up verification activities and
provide verification of kept appointments when
requested, subject to applicable federal, state, and
local confidentiality laws.
• Work with us to establish discharge plans that include
a post-discharge scheduled appointment within
seven days of discharge from an inpatient stay or an
emergency department visit.
• Notify us immediately if a member misses a
post-discharge appointment.
• Promptly complete and submit a claim for services
rendered, confirming that the member kept the
after-care appointment.
• Provide suggestions to us on how we can continue
to improve the collaboration-of-care process.
We annually audit random behavioral health care
professional records to check for communication and
coordination with primary care physicians and other
behavioral health providers and appropriate specialists.
The communication should either be in the form of a
professional letter or in a format that we accept.
We have the right to access confidential medical records
of our members for the purposes of claims payment;
assessing quality of care, including medical evaluations
and audits; and performing utilization management
functions. The Health Insurance Portability and
Accountability Act (HIPAA) privacy regulations allow for
the sharing of protected health information for purposes
of making decisions around treatment, payment or health
plan operations.
HIPAA and release of information
Most health care professionals are familiar with the
Health Insurance Portability and Accountability Act, most
commonly known as HIPAA, and the importance of
upholding its requirements. In short, HIPAA works to
protect the c onfidentiality o f people receiving medical
and behavioral health treatment.
At Aetna®, we work to support your efforts to coordinate
care among our medical and behavioral health providers.
It’s important to follow HIPAA and relevant federal and
state privacy laws to safeguard personally identifiable
information (PII) and protected health information (PHI).
Helpful tips
There is a difference between how behavioral health
practitioners share information with medical providers
and how medical providers share information among
themselves.
For behavioral health information such as general
progress reporting and sharing of details like medication
lists, a signed release may be required by relevant
federal or state law. This release may be required even if
the medical provider seeking the information is also the
one that referred the member to the behavioral health
provider. State and/or other laws may apply. Learn more
about mental health HIPAA requirements and
substance use disorder requirements.
Psychotherapy notes that contain the content of
conversations are not covered under a general release.
Psychotherapy notes require a separate release
of information.
Confidentiality laws govern what and how information
can be shared, and they vary by state. We encourage
both behavioral health and medical providers to find
out about and follow their state regulations.
To enhance coordination of care, obtaining a release of
information from your patient is one way to facilitate
information sharing with other providers and
practitioners.
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Legal disclaimer
The information in this article does not, and is not
intended to, constitute legal advice; instead, all
information, content and materials are for general
informational purposes only. Information may not
constitute the most up-to-date legal or other
information. Links are provided only for the convenience
of the reader, and Aetna® does not recommend
or endorse the contents of third-party sites.
Readers should contact their attorney to obtain advice
with respect to anyparticular legalmatter. No reader
should act or refrain from actingon the basis
ofinformation contained in this article without first
seeking legal advice from counsel in the relevant
jurisdiction. Only your individual attorney can provide
assurances that the information contained in this article
― and your interpretation of it ― is applicable or
appropriate to yourparticular situation.
Quality programs
Quality program overview
We’re committed to a continuous quality improvement
program and encourage your involvement. The Aetna
Behavioral Health Quality program includes:
• A utilization management program
• Quality improvement activities
• Screening programs
• Condition management programs
• Member and provider satisfaction studies*
• Outcome studies experience*
• Provider treatment record review studies*
*Completed for specific states where mandated by law
• Oversight of availability and access to care
• Member safety
• Complaint, nonauthorization and appeal processes
• Medical necessity criteria
• Clinical practice guidelines
• Investigations of potential facility and practitioner
quality-of-care concerns
Participating behavioral health care professionals are
required to support and cooperate with our Aetna
Behavioral Health Quality program, be familiar with our
guidelines and standards, and apply them in their clinical
work. Specifically, behavioral health care professionals
are expected to:
• Adhere to all Aetna policies and procedures, including
those outlined in this manual
• Cooperate with quality improvement activities
• Communicate with the member’s primary care
physician and any specialists (after obtaining a
signed release)
• Adhere to treatment record review standards, as
outlined in Appendix A on page 24 of this manual
• Respond in a timely manner to inquiries by our
behavioral health staff
• Cooperate with our behavioral health
complaint process
• Adhere to continuity-of-care and transition-of-care
standards when the member’s benefits are exhausted
or if they leave the network
• Cooperate with onsite audits or requests for
treatment records
• Return completed annual provider surveys
when requested
• Participate in treatment plan reviews or send in
necessary requests for treatment records in a
timely fashion
• Submit claims with all requested
information completed
• Adhere to patient safety principles
• Comply with state and federal laws, including
confidentiality standards, by maintaining the
confidentiality of member information and records
Annual quality program information and program
evaluation results are detailed on the Quality
Management & Improvement Efforts page on our
website. If you want a hard copy of our quality program
evaluation and don’t have Internet access,
• HMO and Aetna Medicare Advantage plans:
1-800-624-0756 (TTY: 711).
• All other plans: 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
Quality, accreditation, review and
reporting activities
As a participating provider, you agree to cooperate with
any company quality activities, as well as review of the
company, a payer or a plan conducted by, as applicable,
the National Committee for Quality Assurance (NCQA) or
other accrediting organizations, or a state or federal
agency with authority over the company and/or the plan.
Providers must also comply with Healthcare
Effectiveness Data and Information Set (HEDIS) and
similar data collection and reporting requirements as
required by the company.
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Accreditation
Aetna® Behavioral Health is accredited by the NCQA for
both commercial and Medicare health maintenance
organization (HMO) and preferred provider organization
(PPO) products. Many of our policies and procedures are
guided by national accreditation standards.
Visit NCQA.org for more information.
Member rights and responsibilities
We honor the rights of all members and communicate
their rights and responsibilities to them.
Please visit our website at Aetna.com/individuals-
families/member-rights-resources.html to see our
commercial member rights and responsibilities
statements. The language may vary depending upon the
state law applicable to each plan. Medicare members
should refer to their Evidence of Coverage documents for
member rights and responsibilities. Practitioners can
refer to the Office Manual for Health Care
Professionals.
If you want a hard copy of this information and don’t have
Internet access, call us at 1-800-624-0756
(TTY: 711) for HMO-based and Medicare Advantage
plans. Or 1-888-MDAetna (1-888-632-3862)
(TTY: 711) for all other plans.
Nondiscrimination policy
Federal and state laws prohibit unlawful discrimination in
the treatment of patients on the basis of race, ethnicity,
color, gender, creed, ancestry, lawful occupation, marital
status, health status, place of residence, national origin,
religion, age, mental or physical disability, sexual
orientation, claims experience, medical history, evidence
of insurability (including conditions arising out of acts of
domestic violence), disability, genetic information, source
of payment for services, cost or extent of services
required, or any other grounds prohibited by law.
All participating physicians, behavioral health providers
and practitioners should have a documented policy
about nondiscrimination. All participating physicians,
health care professionals and behavioral health providers
may also have an obligation under the federal Americans
with Disabilities Act to provide access to their offices and
reasonable accommodations for patients and employees
with disabilities.
All participating physicians and behavioral health care
professionals who are covered entities under the Section
1557 Nondiscrimination in Health Programs and Activities
Final Rule must also provide access to medical services.
This includes diagnostic services to an individual with
a disability.
Participating physicians and behavioral health care
professionals may use different types of accessible
medical diagnostic equipment. Or they may ensure they
have enough staff to help transfer the patient, as may be
needed, to comply.
Participating behavioral health practitioner
treatment record review criteria and
best practices
Each year, our quality management program randomly
selects Aetna Behavioral Health network practitioners,
in states where it is required, to participate in our
treatment record review. This audit procedure is a key
part of our quality program. It’s important for the network
to comply with standards set by Aetna Behavioral Health,
our customers and external agencies.
Your Aetna Behavioral Health Agreement requires that
you participate in our quality management program.
Refer to Appendix A on page 24 of this manual for our
treatment record review criteria and best practices.
This additional resource is available by
clicking the link below:
• Sample behavioral health forms
Or contact us at QualityImprovement2@Aetna.com
for a copy.
Privacy practices
Protecting our members’ health information is one
of our top priorities. To support this, we tell members
of our policy about the confidentiality of member
information. As a participating physician or behavioral
health care professional, you should know that we
distribute the following notice to our members:
Notice of privacy practices
We consider personal information to be confidential and
have policies and procedures in place to protect against
unlawful use and disclosure. “Personal information”
means information that relates to a patient’s physical or
mental health or condition, the provision of health care to
the patient, or payment for the provision of health care to
the patient.
Personal information doesn’t include publicly available
information or information that is available or reported in
a summarized or aggregate fashion, but doesn’t identify
the patient.
When necessary or appropriate for your care or
treatment, the operation of our health plans or other
related activities, we use personal information internally,
share it with our affiliates and disclose it to health care
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professionals (doctors, dentists, pharmacies, hospitals,
and other caregivers), payers (health care provider
organizations, employers that sponsor self-funded health
plans or share responsibility for the payment of benefits,
and others that may be financially responsible for
payment for the services or benefits a member receives
under their plan), other insurers, third-party
administrators, vendors, consultants, and government
authorities and their respective agents. These parties are
required to keep personal information confidential, as
provided by applicable law. Participating network
physicians and behavioral health care professionals are
also required to give you access to your medical records
within a reasonable amount of time after you make
a request.
Ways in which personal information is used include:
claims payment; utilization review and management;
coverage reviews; coordination of care and benefits;
preventive health, early detection, disease, and case
management; quality assessment and improvement
activities; auditing and anti-fraud activities; performance
measurement and outcomes assessment; health claims
analysis and reporting; health services research; data
and information systems management; compliance with
legal and regulatory requirements; formulary
management; litigation proceedings; transfer of policies
or contracts to and from other insurers, HMOs and
third-party administrators; underwriting activities; and
due diligence activities in connection with the purchase
or sale of some or all of our business.
We consider these activities key for the operation of our
health plans. To the extent permitted by law, we use and
disclose personal information as provided above without
patient consent. However, we recognize that many
patients don’t want to receive unsolicited marketing
materials unrelated to their health benefits. We don’t
disclose personal information for these marketing
purposes unless the patient consents. We also have
policies addressing circumstances in which patients are
unable to give consent.
For a copy of our Notice of Privacy Practices,
which describes our practices in more detail concerning
the use and disclosure of personal information, call the
toll-free Member Services number on the member’s ID
card or visit our website.
Medical record documentation:
standards and criteria
Our participation agreements require you to treat
personal health information (PHI) as confidential. PHI
includes: identity of the individual, the relationship of
the individual with us, physical or behavioral health status
or condition, and payment information for the provision of
health care.
We established medical record criteria to provide a
guideline for fundamental elements of organization,
documentation of diagnostic procedures and treatment,
communication, and storage of medical records.
These criteria are applicable to all benefits plans.
Performance goals are established to assess the
quality of medical record-keeping practices, and
audits are conducted annually. Our performance
goal is 85% compliance.
Our participation agreements require you to keep
medical records in a current, detailed, organized and
comprehensive manner in accordance with customary
medical practice, applicable laws and accreditation
standards. This requirement survives the termination of
the contract, regardless of the cause for termination. You
must keep our members’ information confidential and
stored securely. You must also ensure your staff
members receive periodic training on member
information confidentiality. Only authorized personnel
should have access to medical records.
We have the right to access confidential medical records
of our members for the purpose of claims payment,
assessing quality of care, including medical evaluations
and audits, and performing utilization management
functions. Medical records may be requested as
part of our participation in the Healthcare Effectiveness
Data and Information Set (HEDIS). Health Insurance
Portability and Accountability Act (HIPAA) privacy
regulations allow for sharing of PHI for purposes of
making decisions around treatment, payment or
health plan operations.
Maintenance of information and
records requirements
The provider agrees:
a) To keep information and records in a current,
detailed, organized and comprehensive, accurate
and timely manner, and according to customary
medical practice, applicable federal and state laws,
and accreditation standards
b) That all member medical records and confidential
information will be treated as confidential and
17
according to applicable laws, including but not limited
to, the requirements set forth in 42 C.F.R. §§ 422.118
and 423.136
c) Keep the information and records for the longer of
six years after the last date provider services were
provided to member, or the period required by
applicable law
This requirement survives the termination of your
agreement, regardless of the cause of the termination.
California Assembly Bill 2193 requires maternal
mental health screening
As of July 1, 2019, California Assembly Bill (AB) 2193
requires all licensed health care practitioners who
provide prenatal or postpartum care to a patient to
screen or offer to screen mothers for maternal mental
health conditions. Mental health concerns include not
only depression but conditions like anxiety disorders and
postpartum psychosis that are often missed or mistaken
as “normal” within pregnancy and postpartum periods.
Careful screening can identify those with mental health
conditions and improve the outcome for at least two
patients, if not the whole family.
Practitioners serving Aetna® members can use the
following screening tools:
• The Pfizer Patient Health Questionnaire-9 (PHQ-9)
is appropriate for prenatal screening. This is available
for download at no cost.
• The Edinburgh Postnatal Depression Scale is for
postnatal screening. This is available at no cost.
Scoring references are included for each, and
recommendations are made below. However, the final
determination for referral to treatment resources belongs
to the screening/treating professional.
For prenatal screening with the PHQ-9, any score
under 4 requires no immediate action. For a score of
5 to 14, it is recommended to refer the member to a
behavioral health counselor via the Member Services
number on the member ID card (ask for Aetna
Behavioral Health customer service). And for a score
of 15 or over, refer directly to Aetna Behavioral Health
condition management services by calling
1-800-424-4660 (TTY: 711).
For postnatal screening with the Edinburgh Scale,
any score from 7 to 13 warrants a referral to Aetna
Behavioral Health, which can then make referrals to
behavioral health providers. Any score of 14 or
above suggests a referral directly to Aetna Behavioral
Health condition management services by calling
1-800-424-4660 (TTY: 711).
Note: Scores of 1 or higher on question #10 (self-harm)
should be referred to Aetna Behavioral Health condition
management services immediately for follow-up.
These screening services are reimbursable. Submit
your claim with the following billing combination: CPT
codes 96127 or G0444 (brief emotional and behavioral
assessment) in conjunction with diagnosis code Z13.31
(screening for depression).
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Behavioral health screening programs
Opioid Overdose Risk Screening program
In an effort to address the rising opioid epidemic, we’ve
implemented a screening program to identify members
at risk for opioid overdose. When our clinicians assess a
case involving opioid dependence, they discuss the
potential benefits of adding naloxone (common brands
include NARCAN® and EVZIO®) to the member’s
treatment plan as an intervention, in the event of relapse
and future overdose.*
Naloxone reverses the effects of an opioid overdose.
Providing naloxone rescue kits to laypeople reduces
overdose deaths, is safe, and is cost effective. Other
elements supporting this potentially life-saving
intervention include telling patients and their family and
support network about signs of overdose and about
administering naloxone.
Coverage of naloxone rescue kits varies by individual
plans and can be verified by calling the number on the
member ID card. We waive copays for the naloxone
rescue medication NARCAN for fully insured
commercial members.
Refer patients to our Complex Case
Management program
Complex case management is for members with
complex conditions who need extra help understanding
their health care needs and benefits. Our behavioral
health clinical team works with members to identify those
who may have a coexisting behavioral health and/or
substance use disorder diagnosis We also help them
access community services and other resources. The
program offers an inclusive process for the member, the
caregiver, the providers and Aetna®. Available for
Commercial, Medicare, and Medicare-Medicaid
Dual-eligibility Special Needs (D-SNP) members.
These members will receive:
• An initial screening for coexisting mental health and
substance use disorders using evidenced-based
screening tools
• A individualized care plan (if the screening shows the
co-existing conditions)
• A behavioral health care manager who, as a part of
the care team, will help maintain continuity of care
Program goals
We want to help produce better health outcomes while
managing health care costs. Let’s work together to meet
these goals.
Program referrals
Know a member who could use extra help? Program
referrals are welcome from many sources, including:
• Primary care physicians
• Specialists
• Facility discharge planners
• Family members
• Internal departments
• The member’s employer
Help these members get the care they need
— Make a referral
• Call: 1-800-424-4660 (TTY: 711)
• Email:
AetnaBehav[email protected]
• For Medicare-Medicaid Dual-eligibility Special Needs
Program (D-SNP) members — Refer to Aetna D-SNP
Resources
• Aetna emotional well-being resources
• U.S. Centers for Medicare & Medicaid Services
Roadmap to Behavioral Health
• U.S. Substance Abuse and Mental Health
Services Administration
Depression screening for pregnant and
postpartum women
We work with our medical management team to help
identify depression and behavioral health factors for
pregnant women. The Aetna Maternity Program gives
educational support to members and providers. We help
them reach their goal of a healthy, full-term delivery.
Program elements
• The clinical case management process focuses on
members holistically. This includes behavioral health
and comorbidity assessment, case formulation, care
planning, and focused follow-ups.
• The Aetna Maternity Program refers members with
positive depression or general behavioral health
screens to behavioral health condition management if
they have the benefit and meet the program criteria.
We assess members who have enrolled for any need,
including depression. We case manage members with
a history of any behavioral health issues, as well as a
positive depression screening. We make postpartum
calls to screen for depression. Then, we refer members
to their behavioral health benefit and providers as
appropriate, based on our assessment and screening.
• A behavioral health specialist supports the Aetna
Maternity Program team. They help enhance effective
engagement and identify members with behavioral
health concerns.
*NARCAN is a registered trademark of ADAPT Pharma Operations Ltd. EVZIO is a registered trademark of kaleo, Inc.
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• Aetna Maternity Program nurses reach out to members
who have lost their babies to offer condolences and
behavioral health resources.
How to contact us
• Members and providers can call
1-800-272-3531 (TTY: 711) to verify eligibility or
register for the program. Members can complete
enrollment with a representative, and you can also
refer members by calling this number. This includes
members who are pregnant, as well as members
who have experienced a loss.
• Members can also enroll online through their
member website.
Learn more.
Screening, Brief Intervention and Referral to
Treatment (SBIRT)
SBIRT is an evidence-based practice used to identify,
reduce, and prevent problematic use, abuse, and
dependence on alcohol and illicit drugs. The Institute of
Medicine encourages use of the SBIRT model, which
calls for community-based screening for health risk
behaviors, including substance use.
We’ll reimburse you for screening patients for alcohol
and substance use disorder, providing brief intervention,
and referring them to treatment. You can help increase
the adoption of the SBIRT process in your practice. The
patient must have Aetna medical benefits to be eligible.
The SBIRT practice supports health care professionals in
all health care settings. Overall, our goal is to improve
both the quality of care for patients with alcohol and
substance use disorders conditions, as well as outcomes
for patients, families and communities.
Click here to get started.
Helpful app screens for abuse
The SBIRT app is available as a free download.
The app provides evidence-based questions to screen
for alcohol, drugs and tobacco use. If warranted, a
screening tool is provided to further evaluate the specific
substance use. The app also provides steps to complete
a brief intervention and/or referral to treatment for the
patient, based on motivational interviewing.
Adverse incident reporting
We investigate reports of potential quality-of-care
concerns, which include any adverse incident that takes
place while a member is in care. Examples of potential
quality-of-care concerns include, but aren’t limited to any
completed suicide, serious suicide attempt, or homicide
that takes place within 30 days of discharge from care;
violent member behavior; or adverse outcomes requiring
hospitalization from psychotropic medication. Behavioral
health care professionals and facilities are required to
inform us (using the phone number listed on the member
ID card) as soon as they become aware of a potential
quality-of-care concern for any member in their care.
Teladoc® and other telemedicine services
Telemedicine is the use of telecommunications and
information technology to provide clinical health care
from a distance. It’s used to overcome distance barriers
and improve access to services. There are some states
that have mandates that require coverage of
telemedicine services for fully insured members.
Aetna® Behavioral Health offers telemedicine services to
all commercial fully insured members and to all
commercial self-insured plan sponsors, unless those self-
insured plan sponsors opt out of telemedicine services.
Providers must act within the scope of their license and
ensure that they have the proper licensure based on
state requirements.
Dispute and appeal process
We’ve developed a formal complaint and appeal policy
for physicians, behavioral health care professionals and
facilities. The complaint and appeal process has:
• One level of appeal
Physician, behavioral health care professional and facility
appeals involve payment decisions (claims) but don’t
include dissatisfaction with pre-service or concurrent
medical necessity decisions, which are handled through
the member appeal process.
Note:
The process may vary due to state-specific
requirements. For more information on complaints or
appeals, contact your local Aetna office.
Physician/behavioral health care professional
post-service appeals are classified as payment appeals.
They aren’t considered “on behalf of the member”
unless:
• The appeal explicitly states “on behalf of the member”
• The physician or behavioral health care professional
also submits specific written authorization from
the member
View more information on our appeal process.
Or go to Aetna.com and click “Learn about disputes and
appeals.” According to Centers for Medicare & Medicaid
Services (CMS) requirements, we have a formal process
for Medicare Advantage plan provider dispute
resolution for non-contracted providers.*
Questions?
Just call us at 1-800-624-0756 (TTY: 711) for
HMO-based and Medicare Advantage plans or
20
1-888-MDAetna (1-888-632-3862) (TTY: 711)
for all other plans.
National principles of care
In November 2017, we were one of 16 major health care
payers to commit in writing to the National Principles of
Care for Substance Abuse Treatment. The principles
are derived from the Surgeon General’s Report on
Alcohol, Drugs, and Health and are backed by
three decades of research.
We support these principles, and our goal for all
our members is that they receive these services:
1. Universal screening for substance use disorders
across medical care settings
2. Personalized diagnosis, assessment and
treatment planning
3. Rapid access to appropriate substance use
disorder care
4. Engagement in continuing long-term outpatient care
with monitoring and adjustments to treatment
5. Concurrent, coordinated care for physical and
mental illness
6. Access to fully trained and accredited behavioral
health professionals
7. Access to The U.S. Department of Food and Drug
Administration (FDA)-approved medications
8. Access to non-medical recovery support services
Along with health care providers and the broader
community, we were involved on the task force to
implement needed changes to confront the opioid
crisis. We continue to partner with providers to help
implement these principles, including establishing
measurements of the adoption of these eight key
principles. We believe that universal screening is
important to identification of needs for substance
abuse care. And medication-assisted treatment
is critical in the delivery of high-quality,
evidence-based care.
Member experience survey
Another aspect of our quality program and the services
we provide to our members is the member experience
survey. The results are analyzed to create and implement
improvement activities. The effectiveness of the activities
are monitored and assessed annually. We get feedback
from our members at least annually. The survey covers
the following areas:
• Ease of accessibility to our staff and our
network providers
• Availability of appropriate types of behavioral
health practitioners, providers and services
• Acceptability (cultural competence to meet
member needs)
• Utilization management process
• Coordination of care
Learn more here.
* Aetna Medicare Advantage plans must comply with CMS requirements and time frames when processing appeals
and grie
vances received from Aetna Medicare Advantage plan members. Refer to the Medicare section of the
Office Manual for Health Care Professionals for more information.
21
We also annually evaluate member complaints, appeals
and denials. We collect data in these categories:
• Quality of care
• Access
• Attitude and service
• Billing and financial issues
• Quality of the practitioner’s office site
Practitioner survey
The practitioner experience survey is an additional
quality program activity to get feedback on satisfaction
with the services we provide. We obtain feedback from
behavioral health care professionals annually, and the
survey covers:
• Utilization management process
• Availability and accessibility (self-report)
• Continuity and coordination of care
• Referral to complex case management program
Working
electronically
with us
Electronic solutions for health
care professionals
We offer a variety of easy-to-use electronic options that
are cost-effective and streamline the administrative
process. They make it easy for you to submit eligibility
and benefits inquiries, precertification requests, claims,
and claims status inquiries. These transactions reduce:
• Clerical, administrative and training costs
• Phone calls and reimbursement time
• Paper claims, forms, faxes and duplicate billing
• Errors, lost claims and multiple claims
office addresses
If you don’t use our provider portal, we also work with
various vendors and clearinghouses to offer a suite of
products ranging from no-cost, stand-alone solutions to
integrated systems for electronic transactions. Product
options are available through the internet, by computer
software and by telephone.
If spending less time on the phone and having the
flexibility to submit electronic transactions 24 hours a
day, 7 days a week would benefit your office, we invite
you to learn more about our vendor and clearinghouse
connectivity options.
Go to Aetna.com/provider/vendor to view our
vendor list.
Our provider portal
Our provider portal is a great resource.
You can:
• Check eligibility and benefits
• Send professional claims
• Request precertification
• Look up claims status and precertification
• Get electronic copies of Explanation of
Benefits statements
• Access your patients’ personal health records
• Upload clinical information that’s needed for the
precertification process
You can also:
• Use our cost estimator tool to get a reliable
estimate of your patients’ out-of-pocket expenses
and our payment
• Access resources and tools for behavioral health
providers, such as clinical practice guidelines
• Access pharmacy materials, including formulary
information, pharmacy clinical policy bulletins, and
pharmacy forms
Remember: you can file claims electronically
Filing a claim electronically is easy. Some practice
management or hospital information systems
establish electronic claims submission based on
mailing addresses within claims records or billing
systems. As you validate and update your Aetna®
mailing information, ensure that all Aetna claims are
flagged in your system for electronic submission.
Contact your vendor for help with system setup.
Go to Availity.com to register
or sign in to our provider portal.
Provider data changes
We require that you tell us of data changes within
14 days of the date of the change. Update your profile
online, quickly and easily, on our provider portal.
Registered users can also update their information
on the site.
This process takes only a few minutes to complete.
You can easily update addresses, affiliations and
demographics. Following submission, you’ll get
a confirmation screen that shows that changes will
be made in seven to ten business days.
22
• HMO and Aetna® Medicare Advantage plans call:
1-800-624-0756 (TTY: 711).
• All other plans call: 1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
• All plans can fax the information to us at
860-975-1578 (Attention: MDP Alignment)
All tax ID number changes/additions (unless you’re
joining an existing Aetna health care professional
group) require you to fax a copy of your W-9 form
to 859-455-8650.
How to find this manual online
We update this manual as needed to ensure you have
the most up-to-date, accurate information. If you’re
not currently viewing this document online, you can
find it at Aetna.com in the “For Providers” section, under
Provider Education & Manuals.
If you want a hard copy of this
manual and don’t have
Internet access, call us at:
1-800-624-0756 (TTY: 711)
for HMO-based and Aetna
Medicare Advantage plans
1-888-MDAetna (TTY: 711) or
1-888-632-3862 (TTY: 711)
for all other plans
23
Appendix A:
The Aetna® Behavioral Health treatment
record review criteria and best practices
No Yes N/A No. Standard Instructions
A. Treatment record-keeping practices
N Y 1.
Is the record legible to someone other than
the writer, i.e., does not cause a problem to
read some or a majority of the record? (If
the answer is no, mark all questions ‘N’ and
end review.)
The handwriting should be easy to
read. The reviewer should not have
to make more than two attempts to
read documentation within the
medical record.
N Y 2.
Is the patient’s personal data documented?
For instance, address, gender, date of birth,
home phone numbers, emergency contact,
marital/legal status, and guardianship (if
relevant).
Self-explanatory
N Y 3.
Is the member’s name or unique identifier
on every page?
Self-explanatory
N Y 4.
Are all entries in the record dated? Do they
have the author’s signature or electronic
identifier with title (if applicable) and
degree?
Self-explanatory
N Y 5.
Are there signed release(s) for
communication with Primary Care
Practitioner (PCP), other medical and
behavioral health providers and involved
parties signed?
Self-explanatory
N Y 6.
Are there signed treatment informed
consent forms, if required by the state?
Self-explanatory
24
No Yes N/A No. Standard Instructions
B. Assessment and treatment plan
N Y 7.
Is there a presenting problem including
history and current symptoms and
behaviors? Does it include behavior
onset and development?
Self-explanatory
N Y 8.
Is there documentation of a thorough risk
assessment? Does it include presence or
absence of suicidal or homicidal thoughts?
Self-explanatory
N Y 9.
Is there a completed thorough mental
status examination?
This may be documented on an
assessment tool or in a progress
note. It should include (at least)
most of the elements in the standard.
N Y 10.
Is a substance abuse assessment
completed or ongoing?
For members age 12 and under,
mark “N/A”
N Y 11.
Is there a documented behavioral health
treatment history?
Behavioral health history could
include treatment dates,
practitioners/facilities, current
treating clinicians, response to
treatment, lab tests and
consultation reports (if applicable)
and relevant medical
treatment history.
N Y 12.
Is there a complete assessment of the
family, psychosocial history and cultural
variables? Does it also include legal and
educational variables? Does it include the
source(s) of the information?
Self-explanatory
N Y 13.
Is there a medical history with medical
conditions, medications and allergies
listed (if available)?
Self-explanatory
N Y 14. Is there a diagnosis documented?
Should include comorbid and
relevant psychosocial factors.
N Y 15.
For children and adolescents, is there a
developmental history that could include
prenatal and perinatal events, physical,
psychological, social, intellectual,
academic and educational history?
Self-explanatory
If the member is an adult, this
question will have a score of N/A.
25
No Yes N/A No. Standard Instructions
B. Assessment and treatment plan, continued
N Y 16.
For suicidal and homicidal patients, or
patients who are otherwise at risk, are there
assessments at every session?
For suicidal/homicidal patients,
there should be risk assessments at
every session. If the patient’s
condition is deteriorating, the
record must indicate that more
intense levels of care were
arranged, i.e., IOP, partial, detox,
residential or IP. We score this
question N/A for members that
don’t have these symptoms.
N Y 17.
Is the treatment plan documentation
thorough and complete? Are treatment
plan goals consistent with assessment and
diagnosis? Does each goal have an
estimated timeframe?
(For all psychotherapy) Vague
treatment plan goals will not be
credited.
CA-only members (Autism Spectrum Disorders) Reference California Code of Regulations
Title 28 CCR 1300.67.1(d);28 CCR 1300.80(b); 28 CCR 1300.80(b)(5)€; 28CCR 1300.80 (b)(6)(B).
N Y 18.
If member is 0-6 years of age, was there
screening for Autism Spectrum Disorder?
Document findings from an
assessment tool or summarized in a
progress report. Score N/A if
member is not a CA resident.
N Y 19.
If Autism Spectrum Disorder diagnosis, is
there documentation to support this
diagnosis?
The diagnosis should be consistent
with presenting problems,
behaviors, developmental and/or
appropriate screening tool data.
Score N/A if member is not a
CA resident.
N Y 20.
Does the treatment plan reflect
evidence-based therapies for Autism
Spectrum Disorder?
Does the treatment plan reflect the
outcome of the assessment and
indicate plans to use evidence-
based therapies? Score N/A if
member is not a CA resident.
C. Documentation and practitioner communication
N Y 21.
If you have permission, do you
communicate with the PCP at significant
points of treatment?
PCP communication may occur
after the initial evaluation. This may
result from a significant change in
member status, after a psychiatric
evaluation, the start of medications,
if treatment/diagnosis warrants
such communication, or after
significant changes in medication.
(Score N/A if Q5=N or N/A.)
26
No Yes N/A No. Standard Instructions
C. Documentation and practitioner communication, continued
N Y 22.
With permission, the treatment record
reflects continuity and coordination of care
between primary behavioral health clinician
and other behavioral health specialist(s) or
consultant(s).
There must be a separate release
for each practitioner/provider
treating the member before the
practitioner releases any type of
information about the member.
(Score N/A if Q5=N or N/A)
N Y 23. Is a progress not present for every session? Self-explanatory
CA-only members (Autism Spectrum Disorders) Reference California Code of Regulations
Title 28 CCR 1300.67.1(d); 28 CCR 1300.80(b)(4); 28CCR 1300.80(b)(5)(E); 28CCR 1300.80 (b)(6)(B).
N Y 24.
Is there documentation of collaboration,
consultation and/or continuity of care?
Evidence includes appropriate
release of information and
documentation of a phone
conversation, email correspondence
or a letter. Examples may include the
referring party, the educational
system or any other medical or
behavioral specialist. Score N/A if
member is not a CA resident.
CA-only members Reference California Code of Regulations Title 29 CCR 1300.67.04(c)(4)(A) and 28 CCR1300.70.
N Y 25.
Is there documentation including the
patient’s preferred language?
Records should show
documentation of the member’s
preferred language. Score N/A if
member is not a CA resident.
N Y 26.
Does the treatment plan reflect
evidence-based therapies for Autism
Spectrum Disorder?
Records should show language
help was available to members.
This item is N/A if answer to 25 is
“No” or if member is not a
CA resident.
N Y 27.
Was there was an offer of qualified
interpreter services? If so, does the
documentation note refusal or
acceptance of services?
Rate this question N/A if response
to question 25 or 26 is “No” or the
member is not a CA resident.
27
No Yes N/A No. Standard Instructions
D. Prescribing practitioners only:
These questions score N/A for all non-prescribing practitioners.
N Y 28.
Is there clear documentation of
psychotropic medications, dosages and
dates of changes?
Prescribing practitioner may use
medication flow sheet, order sheet
or progress note to document
psychotropic medications,
dosages, and dates of changes.
N Y 29.
Is there documentation of member
education on the risks and benefits of the
prescribed medications. Is there
documentation that the member
understands the information?
If prescribing practitioner uses a
preprinted medication information
sheet, there still needs to be
documentation the doctor
explained the risks and benefits to
the member. The explanation
should include the possible side
effects and why the provider
prescribed the medication. This is in
addition to the sheet being given.
N Y 30.
Is there documentation reflecting the
patient’s report of efficacy, side effect(s), or
concern about taking the medications as
prescribed?
Self-explanatory
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