AETNA BETTER HEALTH OF KANSAS - Provider Training
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AETNA BETTER HEALTH
OF KANSAS
Provider Training
https://www.aetnabetterhealth.com/kansas/
©2019 Aetna Inc. 1
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Aetna’s Values
©2019 Aetna Inc. 2
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Our Member- The center of what we do
Provider
Experience
Quality Appeals &
Management Grievances
Member
Services & Medical
Member Management
Advocates
Operations & Collaborative
Enrollment Member Services
©2019 Aetna Inc. 3
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Welcome & Introductions
CEO Director of Provider Experience
• Keith Wisdom • Michael McClure
COO Manager, Provider Experience
• Kimberly Glenn • Lesa Castillo
Medical Director Manager, Network
• Dr. Joseph Schlageck • Lydia Jones
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Member Services
Member Services can be reached at 1-855-221-5656, and can help with:
• Eligibility and benefits
• Assisting member with translation services
• Assisting members with available programs and resources
• Assisting member in finding providers
• Assisting members in filing grievances or appeals
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Provider Experience Department
Provider Experience Representatives can be reached at 1-855-221-5656, and can help with:
• Claims questions, inquiries and reconsiderations
• Review claims or remittance advice
• Submitting prior authorizations through the Secure Web Portal (Note: Provider’s are also
able to call our Utilization Management department 1-855-221-5656 or fax prior
authorizations directly to: 1-855-225-4102
• Locating forms
• Finding a participating provider or specialist
• Assisting with provider contracting
• Provide information on how to update location /address changes/provider terminations; via
the KMAP system
• Obtaining a secure web portal ID or member care Login ID
• Scheduling trainings
• Scheduling site visits/meetings with provider’s liaison
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Provider Experience
Provider Experience Manager: Lesa Castillo
Provider Experience Liaisons https://www.aetnabetterhealth.com/kansas/providers
Territory Assigned Provider Liaison Phone Email
Behavioral Health Kansas Erin Pettera 316-347-1027 petterae@aetna.com
HCBS Angela Cummings 620-238-1647 cummingsa1@aetna.com
HCBS IDD Eastern Emily Lloyd 785-991-1490 lloyde@aetna.com
HCBS IDD Western Jesse Cruz 620-518-0332 cruzj8@aetna.com
Barber, Barton, Harper, Harvey, Kingman, Reno, Rice, Summer, Stafford Angie DeJesus 316-633-0613 dejesusa3@aetna.com
Atchison, Brown, Clay, Cloud, Dickinson, Doniphan, Ellsworth, Geary, Jackson, Jewell,
Lincoln, Marshall, Mitchell, Nemaha, Pottawatomie, Republic, Riley, Wabaunsee,
Washington Emily Lloyd 785-991-1490 lloyde@aetna.com
Cheyenne, Clark, Comanche, Decatur, Edwards, Ellis, Finney, Ford, Gove, Graham,
Grant, Gray, Greeley, Hamilton, Haskell, Kearney, Kiowa, Lane, Logan, Meade,
Morton, Ness, Norton, Osborne, Pawnee, Phillips, Pratt, Rawlins, Rooks, Rush, Scott,
Seward, Sheridan, Sherman, Stanton, Stevens, Thomas, Trego, Wallace, Wichita Jesse Cruz 620-518-0332 cruzj8@aetna.com
Bourbon, Cherokee, Crawford, Linn, Miami Katie Rohlfing 785-596-8262 rohlfingk@aetna.com
Butler, Chase, Cowley, Marion, McPherson, Morris Melissa Rogers 316-251-1672 rogersm2@aetna.com
Allen, Anderson, Chautauqua, Coffey, Douglas, Elk, Franklin, Greenwood, Labette,
Lyon, Montgomery, Neosho, Osage, Woodson, Wilson Nicole Kennedy 785-596-8407 kennedyn@aetna.com
Jefferson, Leavenworth, Shawnee, Wyandotte Vincent Cailteux 785-596-8439 cailteuxv@aetna.com
Sedgwick; Zip Codes: 67106, 67108, 67118, 67120, 67135, 67147, 67149, 67201-
67205, 67209, 67212-67213, 67215, 67217, 67223, 67227, 67235, 67260, 67275-
67278, 67543 Angie DeJesus 316-633-0613 dejesusa3@aetna.com
Sedgwick; Zip Codes: 67001, 67016-67017, 67020, 67025-67026, 67030-67031,
67037, 67039, 67050, 67052, 67055, 67060, 67067, 67101, 67110, 67133, 67206-
67208, 67210-67211, 67214, 67216, 67218-67220, 67226, 67228, 67230, 67232 Melissa Rogers 316-251-1672 rogersm2@aetna.com
Johnson County; HCA Direct Contracted Hospital/Ancillary/Physician Groups Katie Rohlfing 785-596-8262 rohlfingk@aetna.com
Johnson County; All Providers that are not HCA direct contracted
Hospital/Ancillary/Physician Groups Vincent Cailteux 785-596-8439 cailteuxv@aetna.com
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Public website
Members and Providers can access the Aetna Better Health of Kansas website at
www.aetnabetterhealth.com/kansas
Through the website, providers will be able to access:
• The secure provider web portal
• Our provider manual, communications, bulletins and newsletters
• A searchable provider directory and electronic provider directory
• Important forms
• Clinical practice guidelines
• Member & Provider materials
• Fraud & abuse information and reporting
• Information on reconsideration and provider appeals
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Member Website
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Provider Website
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©2019 Aetna Inc. 11
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©2019 Aetna Inc. 12
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Our web portal will allow providers to:
• Search member eligibility and verify enrollment
• Search and initiate authorizations (CareWebQI)
• Search claims status
• View claim detail, explanation of benefits and remittance advice
• View provider lists and panel roster
• Contact the health plan via secure messaging
• Review HEDIS gaps in care
Registration:
• Your Administrator for the Secure Portal will complete Registration form
https://www.aetnabetterhealth.com/kansas/assets/pdf/providers/forms/Aetna%20Better%20
Health%20of%20Kansas%20Web%20Portal%20Registration.pdf
• Print and then complete the form in its entirety Fax your form to: (855) 215-8760 or Email it
to: ProviderExperience_KS@aetna.com
Note: Each TIN will have one account, with a primary administrator.
• The primary representative can add authorized representatives within their office to their
account
• Provider Experience Team can assist with connecting all Groups NPI’s to the Groups TIN for
your Users
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https://medicaid.aetna.com/MWP/login.fcc
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Search Authorizations – Allows users to search for authorizations. Searches can be refined by
providing search criteria such as Authorization Status or Authorization Date Range.
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ProprietaryProvider Secure Web Portal
Search Authorization Results Authorization Details – On click of the Authorization ID link,
the authorization details will be displayed.
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ProprietaryProvider Secure Web Portal
Search Authorization Results
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ProprietaryProvider Secure Web Portal
Search Claims – Allows user to search for claims. The search can be refined by providing search
criteria such as Claim Status, Claim Type, Date Range, etc.
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ProprietaryProvider Secure Web Portal
Search Claims Results
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ProprietaryProvider Secure Web Portal
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Search Remittances – Allows user to obtain and display remittance advice detail based upon a
paid claim. This page allows the user to search for (and generate) a list of paid claims.
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ProprietaryProvider Secure Web Portal
Search Remittances Results
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ProprietaryProvider Secure Web Portal
Search Members – Allows user to search for a member. The search criteria includes Last Name,
Date of Birth or Member ID.
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ProprietaryProvider Secure Web Portal
Search Member Results
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ProprietaryProvider Secure Web Portal
Search Member Results
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ProprietaryMedical Prior Authorization
The online prior authorization search tool can also be used to determine if
prior authorization (PA) is required for services.
You may submit prior authorization requests to us 24-hours-a-day, 7-days-a-week
through one of the options below:
• Secure Web Portal
• Fax (Toll Free 1-855-225-4102 )
• Phone (1-855-221-5656)
Please submit the following with each authorization request:
• Member Information, e.g., correct and legible spelling of name, ID number,
date of birth, etc.
• Diagnosis Code(s)
• Treatment or Procedure Codes
• Anticipated start and end dates of service(s) if known
• All supporting relevant clinical documentation to support the medical
necessity
• Include an office/department contact name, telephone and fax number
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ProprietaryPrior Authorization Decision Timeframes
Decision Turnaround Times
Urgent pre-service approval Within seventy-two (72) hours from receipt of
request
Non-urgent pre-service approval Within fourteen (14) calendar days from
receipt of the request
Urgent concurrent approval Within seventy-two (72) hours from receipt of
request
Post-service approval Within thirty (30) calendar days from receipt of
the request.
Additional timeframes are located in our provider manual.
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Under Health Tools select “Submit Authorizations”
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ProprietaryAuthorization
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ProprietaryProvider Manual
Our Provider Manual is available online at www.aetnabetterhealth.com/kansas
under the “For Provider” tab under Provider Manual
In addition to policies and procedures, this resource includes:
• Important contact information (located in Chapter 2 of the Provider Manual)
• Provider responsibilities & Important Information (located in Chapter4 of the Provider
Manual)
• Credentialing (located in Chapter 4 of the Provider Manual)
• Member eligibility and enrollment (located in Chapter 4 of the Provider Manual)
• Billing and claims (located in Chapter 17 of the Provider Manual)
• Grievances, Reconsiderations, Appeals and State Fair Hearings (located in Chapter 18 of the
Provider Manual)
• Utilization management program and requirements (located in Chapter 13 of the Provider
Manual)
• Quality Improvement program (located in Chapter 14 of the Provider Manual)
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ProprietaryCovered Services
For a complete list of benefits, added benefits and non-covered services, please
refer to our Provider Manual at www.aetnabetterhealth/Kansas.com
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ProprietaryMedication Drug Coverage
We reimburse for covered Preferred Drug List (PDL) Prescriptions
https://www.aetnabetterhealth.com/kansas/providers/pharmacy
• No copayments on medications
• We may deny a claim if the referring physician fails to provide their NPI
number, and or if referring physician is not credentialed through us.
• The following documents are available online:
−Preferred Drug List (PDL)
−Prior Authorization Form
−Mail Order Form
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ProprietaryMedical Necessity
Medically necessary services are accepted services and supplies provided by health care
entities, appropriate to evaluation and treatment of a disease, condition, illness, or
injury and consistent with the applicable standard of care. Determination of medical
necessity is based on specific criteria.
This definition is based on Kansas Administrative Regulations (K.A.R.) 30-5-58, the
Centers for Medicare & Medicaid Services (CMS), and American College of Medical
Quality (ACMQ) definitions. Such services are:
• Provided for the diagnosis or direct care and treatment of the medical condition
• To achieve age appropriate growth and development
• To attain, maintain, or regain functional capacity
• Meet national clinical standards and the standards of good medical practice within
the medical community in the service area
• Not primarily for the convenience of the plan member, caregiver, or a plan provider
• The most appropriate level or supply of service which can safely be provided
You can view a current list of the services requiring authorization on our website at:
www.aetnabetterhealth.com/kansas
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ProprietarySample ID Card
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ProprietaryClaim Submission
Aetna Better Health encourages participating providers to submit claims electronically.
With our vendor Change Healthcare (see next slide for portal information).
With our vendor Office Ally for professional 1500 claims and institutional UB4 claims.
Through a clearinghouse but first you need to confirm your clearinghouse is compatible with
Change Healthcare.
Please use the following Provider ID and Submitter ID when submitting claims to Aetna Better
Health of Kansas:
• Payer ID’s: 128KS (Claim Submission) and ABHKS (Real-Time)
Paper Claims:
Aetna Better Health of Kansas
P.O. Box 61838
Phoenix, AZ 85082-7540
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ProprietaryProvider Secure Web Portal
Direct submission of claims – Available through our Secure Provider Portal with our vendor
Change HealthCare.
What type of claims can be submitted?
− Institutional (UB04), Professional (1500) claims with an option for 837 file submission or manual
entry claims.
− Also accepts resubmission claims known as a corrected or voided claim.
− Claims where there is other insurance that is primary to Medicaid.
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ProprietaryClaim Submission
Please note that we follow Kansas billing practices, (i.e., required diagnosis codes, CPT, HCPCs and
associated modifiers), and Kansas’s fee schedule methodologies. We also follow Kansas’s timely
filing requirements along with the claim dispute processes and timeframes.
Common Barriers
• 5010 Requirements (Rendering NPI and pay-to NPI; Both are required)
• NDC Codes Missing or Incomplete
• Lack of Prior Authorization
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ProprietaryClaim Submission – continued
Resubmissions
• Electronic and paper resubmitted claims are accepted, however, we prefer electronic claims.
Resubmitted claims must be labeled appropriately.
• Our Provider Experience staff, Manager or the COO are available for any escalated issue
and/or concerns.
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ProprietaryProvider Disputes, Grievance & Appeals
Provider Grievance
Both network and out-of-network providers may file a grievance verbally or in writing directly with
us in regard to our policies, procedures, or any aspect of our administrative functions including
dissatisfaction with the resolution of a dispute within 180 calendar days from the incident being
grieved.
Provider Reconsiderations
A provider may request a claim reconsideration if they would like us to review the claim decision.
Claim reconsideration is available to providers prior to submitting an appeal. Reconsideration
requests must be submitted within 120 calendar days (an additional 3 day calendar days is
allowed for mailing time) from the date of the notice of the claim denial.
We acknowledge provider reconsiderations in writing within 10 calendar days of receipt. Aetna
Better Health will review reconsideration requests and provide a written response within 30 calendar
days of receipt.
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ProprietaryProvider Disputes, Grievance & Appeals Cont.
Provider Appeal
A provider may file an appeal in writing, if they are not satisfied with the outcome of the
reconsideration determination or if they wish to bypass the reconsideration process. A provider may
file an appeal within 60 calendar days (an additional 3 calendar days is allowed for mailing time)
of the date of the notice of adverse action, if no reconsideration was requested. If reconsideration was
requested, providers have 60 calendar days (an additional 3 calendar days for mailing time) from the
date of the reconsideration resolution letter to file an appeal. Post service items or services are
standard appeal and are not eligible for expedited processing.
Provider State Fair Hearing
Providers may request a State Fair Hearing through the Office of Administrative Hearings after the
appeal with Aetna Better Health. This request must be completed within 120 calendar days (an
additional 3 calendar days for mailing time), file following the date of the appeal resolution letter.
Information on how to submit a State Fair Hearing request is included in Appeal Resolution Letter.
Providers may request a State Fair Hearing for a denial of payment for covered services. Providers
may also request a State Fair Hearing regarding an incorrect payment by Aetna Better Health or a
notice from Aetna Better Health regarding an overpayment.
For additional details around Provider Disputes, Grievances & Appeals, please see chapter 18 of
the Aetna Better Health of Kansas Provider Manual.
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ProprietaryProvider Communications
Provider Newsletters
Participating network providers will receive newsletters via our website and secure portal. The
purpose of our newsletters is to provide a consistent and reliable method of communication with
participating network providers.
Special Provider Communications
Special provider communications are used to distribute information updates to our provider
practices, when the distribution and implementation timeline for the information (e.g., new
evidence-based practice guidelines) precedes the next regularly scheduled provider communication.
Bulletins
Bulletins can come from either Aetna Better Health or the state. These bulletins are available on our
website. Historical bulletins are also available on our website.
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ProprietaryMember Rights & Responsibilities
It is our policy not to discriminate against members based on race, national origin, creed, color,
gender, gender identity, sexual preference, religion, age, and health status, physical or mental,
disability or any other basis that is prohibited by law. Please review the list of member rights and
responsibilities in the Provider Manual. Please see that your staff is aware of these requirements
and the importance of treating members with respect and dignity.
In the event that we are made aware of an issue with an member not receiving the rights as
identified above, we will initiate an investigation into the matter and report the findings to the
Quality Management Committee and further action may be necessary.
For a complete list of member’s right and responsibilities, please review the Provider Manual. This
list can also be found on our website.
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ProprietaryMedical Records Standards
Provider are required to maintain clinical and medical records in a manner that is current, detailed
and organized; and, which permits effective and confidential patient care and quality review,
administrative, civil and/or criminal investigations and/or prosecutions.
Providers are required to retain and make available all records pertaining to any aspect of services
furnished to a members or their contract with Aetna Better Health for inspection, evaluation, and
audit for the longer of:
• A period of 10 years from the date of service
• 10 years after final payment is made under the provider’s agreement and all pending matters
are closed.
Additional Information:
• Providers must maintain member records in either a paper or electronic format.
• Providers must also comply with HIPAA security and confidentiality of records standards.
• Providers must respond to these requests promptly within 14 days of request. Medical records
must be made available to the state for quality review upon request and free of charge.
Our standards for medical records have been adopted from NCQA and the Medicaid Managed Care
Quality Assurance Reform Initiative (QARI).
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ProprietaryAetna Better Health of Kansas Partners
Dental
• SKYGEN
- Phone-1-855-918-2256
- Email-www.SKYGENusa.com
Vision
• SKYGEN
- Phone-1-855-918-2258
- Email-www.SKYGENusa.com
Radiology and Pain Management
• Evicore
- Phone-1-888-693-3211
- Email-www.evicore.com
Non-Emergent Transportation
• Access2Care
- Phone-1-866-252-5634
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ProprietaryQuestions
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ProprietaryThank you
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