New Jersey Providers Chiropractic services




CHANGES EFFECTIVE 04/01/13

Effective April 1, 2013, Aetna has resumed responsibility for credentialing, network management, utilization management and claims processing of chiropractic services under their PPO-based products. Triad will continue to manage the chiropractic benefit for Aetna HMO, HNO and Medicare Advantage plans. For further detail regarding the programs, please reference below.

FOR DATES OF SERVICE PRIOR TO 4/1/13, PLEASE CLICK HERE.

FOR DATES OF SERVICE 4/1/13 AND AFTER PLEASE FOLLOW THE INSTRUCTIONS BELOW.

Aetna HMO-based, Health Network Option/Only and Medicare Advantage plan In 2006, Aetna delegated the administration of chiropractic benefits to Triad Healthcare, Inc. (Triad) for their Northern New Jersey HMO-based members (including Medicare Advantage) based plans in New Jersey. This delegation includes responsibility for credentialing, network management, utilization management and claims processing. This relationship was expanded in 2010 to include Aetna’s Southern New Jersey HMO-based members (including Medicare Advantage-based plans) and was further expanded to include Aetna’s Health Network Option/Only (HNO)-based plans.

Claim submission: The following information provides an overview of where to submit your Aetna New Jersey Chiropractic claims.

Aetna/Triad Claims Submission Instructions

“Provider Classes” based on network participation status and affirmative agreement to plan participation:

1.  Aetna/Triad Par - Participating provider with both Aetna and Triad.
2.  Aetna Par only - Participating provider with Aetna, Non Participating with Triad.
3.  Non Participating with Aetna.

“Member Classes” based on Aetna product participation and product inclusion in Aetna/Triad arrangement:

1.  HMO-based, Health Network Option/Only (HNO) and Medicare Advantage plans
2.  PPO
3.  Excluded Aetna NJ plans (Flexible Spending Accounts FSA, Health Savings Accounts HSA, Aetna Workers’ Comp Access®, Cofinity®, Strategic Resource Company, Aetna Signature Administrators®)
4.  HMO Excluded Plan Sponsors (see HMO based products Excluded Plan Sponsors) .These groups are excluded from claims processing by Triad.


Provider Class 1: Aetna/Triad Par
 Member Class  Submit Claims to
    1.  HMO including HNO & Medicare
    2.  PPO
    3.  Excluded Aetna NJ plans
    4.  HMO Excluded Plan Sponsors
Triad
Aetna
Aetna
Aetna


Provider Class 2: Aetna Par Only, Non Participating with Triad
 Member Class  Submit Claims to
    1.  HMO including HNO & Medicare
    2.  PPO
    3.  Excluded Aetna NJ plans
    4.  HMO Excluded Plan Sponsors
Triad
Aetna
Aetna
Aetna


Provider Class 3: Non Participating with Aetna*
 Member Class  Submit Claims to
    1.  HMO including HNO & Medicare
    2.  PPO
    3.  Excluded Aetna NJ plans
    4.  HMO Excluded Plan Sponsors
Aetna
Aetna
Aetna
Aetna


*Note: The member’s plan determines whether a claim is a covered charge. If a member’s plan does not include out-of-network benefits, then coverage may not be provided.

Submission Guidelines

  TriadHealthCare
   

Electronic Submission: Triad Healthcare, Inc. has partnered with MD On-Line for electronic claim submission. Claims can be individually entered free of charge. To access this benefit, log on to http://triadhealthcareinc.com/providers/onsolution.aspx and click the “Submit” button under Online Solutions. This will route you to MD On-Line’s portal for Triad’s providers. Please include Triad’s address (see below) and electronic payer ID #39181. To learn more about MD On-Line’s products for submitting Triad claims electronically free of charge, please call: 1-888-499-5465.

    Paper claims can be submitted directly to Triad at:

Triad Healthcare, Inc.
Claims Department
80 Spring Lane
Plainville, CT 06062

    Please refer to the information outlined in the Required Information for all Claim Submission section of the Provider Manual.
  Aetna  
   

Submit claims to Aetna at the address listed on the back of the member’s ID card.

Reimbursement

Claims are adjudicated according to the Triad/Aetna fee schedule. The fee schedule is subject to a Maximum Daily Allowed Amount per date of service for new patients, established patients with evaluation service(s) and established patient’s routine visit. Participating providers can request a copy of the Triad/Aetna fee schedule, by calling Triad’s Customer Service Department – 1-800-409-9081. Further information can be found in Triad’s published notice #197 - http://triadhealthcareinc.com/providers/PDFview.aspx?fld=notices&fn=Fax197.pdf

Utilization Management

Triad applies an initial 10 visit threshold BEFORE performing utilization review. This applies to all new patients and existing patients with a new condition. Preventive medicine and established patient evaluation/diagnostic services will be reviewed for medical necessity. Please refer to published notice # 191 - http://triadhealthcareinc.com/providers/PDFview.aspx?fld=notices&fn=Fax191.pdf for further instruction.

As a participating provider in Triad’s network, you have the option to prior authorize the care that you deliver to your patients. While prior authorization is completely voluntary most providers elect to use this process. Prior authorization is accomplished with the use of Triad’s “Physical Medicine Authorization Form”. Physical Medicine Authorization forms are available on Triad’s website (http://triadhealthcareinc.com/providers/forms.aspx).

Things to note regarding Triads utilization management services:

  • The 10 visit threshold will be applied to all new HMO-based, Health Network Option/Only and Medicare Advantage patients who are seen for the first time on or after June 1, 2012.
  • The 10 visit threshold will be applied to established HMO-based, Health Network Option/Only and Medicare Advantage patients who present for care for a new condition for the first time on or after June 1, 2012.
  • The 10 visit threshold does not apply to preventive medicine and established patient evaluation/diagnostic services. Triad may request medical records to substantiate medical necessity.
  • The 10 visit threshold is not a calendar year benefit and does not reset on January 1st of each year.
  • Further detail regarding Triad’s voluntary prior authorization process: Please refer to the published notice # 190 - http://triadhealthcareinc.com/providers/publishednotices.aspx
  • Medical records are required to be submitted with the Physical Medicine Authorization form.
  • Prior approval is required for Medicare members ONLY.
  • Physical Medicine Authorizations will be valid for six (6) months from the date of the determination.
  • Triad’s programs do not require a PCP referral for chiropractic services; however, any Aetna plans that currently require a PCP referral will continue to do so. Please contact Aetna to determine if your patient requires a referral.
  • Maintenance Care, Wellness Care and Scheduled Supportive Care are not covered. Please refer to published notice # 193 - http://triadhealthcareinc.com/providers/PDFview.aspx?fld=notices&fn=Fax193.pdf

Medical Policies

For a complete list of Triad HealthCare’s medical policies, access Triad HealthCare’s website at http://www.Triadhealthcareinc.com/providers/policies.aspx.

Peer to Peer

If you wish to speak with a Clinical Peer at anytime, please call Triad’s Customer Service at 1-800-409-9081 and a representative can assist you.

Network participation

All Aetna participating providers are required to sign an addendum to the Triad Healthcare Aetna Participating Provider Agreement. Aetna plans to non-renew agreements with chiropractors who are currently participating with Aetna for HMO products, but who have decided not to join the Triad Healthcare network for HMO products. The effective date of non-renewal by Aetna will be based on the provider’s contract with Aetna. This will begin with second quarter, 2013 contract renewals. Aetna will provide providers with 90 days prior written notice of the non-renewal.

If you elect to not participate with Triad Healthcare you may still see Aetna patients. However, coverage will only be provided if the member’s plan includes out-of-network benefits. The member will be responsible for the out-of-network cost-sharing for these services.

If you have questions regarding network participation, please call Triad’s Customer Service Center at 1-800-409-9081.

Point of Service Plans

Aetna has three Point of Service products:

1.  Quality Point of Service (QPOS®)Plan- This plan is either an HNO or HMO-based plan.
2.  Aetna Choice® POS Plan–This is an HMO-based plan.
3.  Aetna Choice ™ POS II –This is a PPO-based plan.

Appeals

UR Appeals: Triad does not handle clinical appeals. Submit all clinical appeals to Aetna at the address listed on the Explanation of Benefits and on the Determination Letter.

NJ Prompt Pay/Administrative Denial Appeals:
All providers may initiate an administrative claim appeal on or before the 90th calendar day following receipt of the claims determination. These appeals should be completed using the Health Care Provider Application to Appeal a Claims Determination Form (NJ Only) and mailed or faxed to Triad (see below). This form can be found on-line at our website www.triadhealthcareinc.com under the Forms & Instructions section.

Claims Appeals should be sent directly to Triad at:

Triad Healthcare, Inc.
Appeals Department
80 Spring Lane
Plainville, CT 06062
Fax: 860-793-3317

If you disagree with Triad’s administrative claim appeal decision, you may obtain an external review by initiating an arbitration proceeding within 90 calendar days of receipt of an uphold notice. The New Jersey Department of Banking & Insurance has contracted with MAXIMUS, Inc. as the Arbitration Organization (AO) to operate the Program for Independent Claims Payment Arbitration (PICPA). Health care providers may submit an Application for Arbitration online at https://njpicpa.maximus.com. For more information, please contact MAXIMUS by phone, fax or mail at:

MAXIMUS, Inc.
Attn: New Jersey PICPA
50 Square Dr., Suite 210
Victor, NY 14564
P#: (585) 425-5326
F#: (585) 425-5296

Customer service

Contact Triad’s Customer Service Department at 1-800-409-9081, Monday-Friday from 8:00 AM to 6:00 PM EST.