Patient care programs & quality assurance.BCBS prefix List plays a vital role in filing the health care claims properly to the correct BCBS address and also to verify member’s eligibility, health insurance coverage information and to reach the correct BCBS department to check the claim status or disputes of the claim.Claims, payment & reimbursement overview.Secure provider website opens in secure siteīy clicking on “I Accept”, I acknowledge and accept that.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. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. 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. 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. 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. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. 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.Federal Agencies Extend Timely Filing and Appeals Deadlines June 24, 2020Īs a result of the National Emergency declared on March 1, 2020, the Employee Benefits Security Administration, Department of Labor (DOL), Internal Revenue Service and the Department of the Treasury extended certain timeframes to ease the burden of maintaining benefits and compliance with notice obligations. What does this mean? In compliance with the guidelines, between March 1, 2020, and 60 days after the announced end of the National Emergency, the following periods and dates are suspended: We will follow these guidelines.Īpplies to: This is for members of all fully insured and self-funded groups that are regulated by the Employee Retirement Income Security Act. The date within which individuals may file a claim.The date within which claimants may file an appeal of an adverse benefit determination.The date within which claimants may file a request for external review after receiving an adverse determination.To help providers and individuals meet timely filing rules, the period from March 1, 2020, to 60 days after the announced end of the National Emergency will not count towards timely filing requirements. Timely filing limits may vary by state, product and employer groups. Situation (assume 180-day timely filing rule) – The time for a claim to fulfill the timely filing rule expired on Feb. Outcome – The rules to suspend timely filing do not apply. Situation (assume 180-day timely filing rule) – Service was rendered on Sept. The claim entered day 179 of the 180-day timeline on Feb. Outcome – The time to file this claim is suspended starting on March 1, 2020, until 60 days after the National Emergency is declared over. If the National Emergency were over on June 1, 2020, 60 days later is July 31, 2020. On July 31, one day remains to file the claim. Situation (assume 180-day timely filing rule) – The date of service was March 1, 2020.
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