Studies ............................................................................ 32
Communication ............................................................. 32
Records maintenance and access ................................ 32
Maintenance .................................................................. 32
Member record access ................................................ 32
Privacy practices ............................................................... 33
Referrals .............................................................................. 34
Referral policies .................................................................34
Referral requirements...................................................34
When referrals are not required ................................. 34
Notice and termination .................................................34
Member’s consent for nonparticipating
providers’ referrals ............................................................ 35
Referral processes ........................................................ 35
Utilization management ....................................................35
Overview ............................................................................ 35
Utilization management and standards ........................35
How to contact us about utilization
management issues .........................................................36
Utilization review policies .................................................36
How we determine coverage..........................................36
Admissions protocol ......................................................... 37
Notify us of hospital admissions within
two business days ............................................................ 37
All-products precertication list ..................................... 37
Member programs and resources .................................. 38
Member programs ...........................................................38
Care management ........................................................38
Disease management ..................................................38
Aetna® Healthy Lifestyle Coaching program ............38
Aetna® Lifestyle and Condition Coaching
program ..........................................................................39
Fitness programs for Aetna Medicare Advantage
members ........................................................................39
Aetna Women's Health Program ................................39
Member resources ...........................................................39
24-Hour Nurse Line ......................................................39
Institutes of Excellence® network ........................... 39
Institutes of Quality® designation ............................39
Aetna Institutes® Gene-based, Cellular and
Other Innovative Therapies (GCIT®)
Designated Networks ...................................................39
Behavioral health ..............................................................39
Behavioral Health Accessibility standards* and
participation criteria ......................................................40
Behavioral Health Screening Programs ....................40
Complex Case Management ......................................40
The Aetna® Depression in Primary Care Program ...40
Screening, Brief Intervention and Referral to
Treatment (SBIRT) practice ..........................................41
The Aetna Opioid Overdose Risk
Screening Program ........................................................41
D-SNPs screening for coexisting behavioral
health and substance use disorders ...........................41
Pharmacy management and drug formulary ................42
Overview of the Pharmacy Plan
Drug List (formulary) ........................................................ 42
Commercial plans .........................................................42
Aetna Medicare Prescription Drug Plans ..................42
Requirements for Part B drugs ....................................... 42
How your patients can learn more ............................. 42
Treating complex diseases and
chronic conditions ........................................................43
Ordering through CVS Specialty is easy ...................43
Electronic prescribing .................................................43
Pharmacy clinical policy bulletins ..................................43
Precertication .................................................................. 43
Step therapy ......................................................................43
Quantity limits....................................................................44
Generic drugs ....................................................................44
Medical exception and precertication..........................45
Performance programs .....................................................46
Quality, accreditation, review and
reporting activities ............................................................46
Aexcel® network of specialist doctors ...........................46
Patient-centered medical home (PCMH) .....................46
Physician pay for performance (P4P) ........................ 47
Clinical medical management ......................................... 47
Clinical practice and preventive service guidelines ....47
Clinical practice guidelines .............................................48
Behavioral health clinical practice guidelines ..............48
Preventive services guidelines .......................................48
Case management ...........................................................48
Coordination of care ..........................................................49
Importance of collaboration ............................................49
Sharing patient information .............................................49
Accessing communication forms ..................................49
Transition of care ..............................................................49
The four steps for requesting transition of care .......50
Complaints and appeals....................................................50
Medicare .............................................................................. 51
Aetna Medicare Advantage plans* .................................51
Aetna Medicare health maintenance
organization (HMO) plans and Aetna Medicare
HMO Prime plans ...........................................................51
Aetna Medicare HMO plans with open access .........51
Aetna Medicare preferred provider
organization (PPO) plans and Aetna Medicare
PPO Prime plans ............................................................51
Aetna Medicare Advantage plans
(HMO and PPO) ..............................................................51
Aetna Medicare Advantage HMO plan .......................51
Aetna Medicare Advantage PPO plan
........................51
Home assessment program ........................................... 52
Quality improvement program .......................................52
Medicare prescription drug plan ................................... 52
Transition-of-coverage (TOC) policy .......................... 53
Additional prescription drug plan information ............. 53
Preferred pharmacies ..................................................54
Part D drug rules ...........................................................54
Home infusion ...............................................................54
Additional Aetna Medicare Advantage information ....55
Physician-member communications policy .............55
Demographic data quarterly attestation ....................55
Collecting all Aetna Medicare Advantage plan
member cost sharing ...................................................55
Access to facilities and records ..................................56
Access to services ........................................................56
*FOR BEHAVIORAL HEALTH ACCESS STANDARDS: unless state requirements are more stringent.
*FOR AETNA MEDICARE ADVANTAGE PLANS: Plans must comply with CMS requirements and time frames when
processing appeals and grievances received from Aetna Medicare Advantage plan members. Refer to the Medicare
section, which begins on page 52 of this manual, for further information.
3