In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. a deductible, co-insurance, co-payment or other patient responsibility also must. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. It is important to follow these guidelines or your claims may be denied for timely filing. Some are as short as 30 days and some can be as long as two years. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. One major problem medical billers encounter is when claims are denied for timely filing because each insurance carrier has its own guidelines for filing claims in a timely fashion. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. SECONDARY FILING must be received at Cigna-HealthSpring within 120 days from the date on the Primary Carrier’s EOB. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. CLAIM TIMELY FILING POLICIES To ensure your claims are processed in a timely manner, please adhere to the following policies: INITIAL CLAIM must be received at Cigna-HealthSpring within 120 days from the date of service. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice.
TIMELY FILING PATIENT RESPONSIBILITY CODE
The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. Transfer claims must be filed with TMHP on an electronic institutional claim or the UB-04 CMS-1450 paper claim form using admission type 1, 2, 3, or 5 in block 14, source of admission code 4 or 6 in block 15, and the actual date and time the client was admitted in block 12 of the UB-04 CMS-1450 paper claim form. Secure provider website opens in secure siteīy clicking on “I Accept”, I acknowledge and accept that:.Claims, payment & reimbursement overview.Patient care programs & quality assurance.
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