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Summary of “Key” Aetna Settlement Provisions

Coding Rules

Aetna shall comply with most American Medical Association (AMA) Current Procedural Terminology (CPT®)* codes, guidelines and conventions.

No automatic downcoding of any evaluation and management (E/M) CPT code for covered services.

If a bill contains a CPT code for the performance of an E/M CPT code appended with a modifier 25 and a CPT code for the performance of a non-E/M service procedure code, both codes will be recognized and eligible for payment.

A CPT code appended with a CPT modifier 59 will be recognized and separately eligible for payment to the extent that they designate a distinct or independent proce- dure performed on the same day by the same physician.

No CPT modifier 51 exempt CPT codes are subject to the multiple procedure reduction logic or rule.

Supervision and interpretation CPT codes are separately identifiable and payable.

“Add-on” codes, as designated by CPT, will be recognized and eligible for payment as separate codes and shall not be subject to the multiple procedure logic or rule.

A CPT code will not be automatically changed to a CPT code reflecting a reduced intensity of the service when such CPT code is one among a series that differentiates among simple, intermediate and complex.

Recommended vaccines and injectibles, as well as the administration of these vaccines and injectibles, will be reimbursed as appropriate.

No global period for surgical procedures will be longer than any period designated on a national basis by the Centers for Medicare and Medicaid Services (CMS) for such surgical procedures.

Disclosure of Fee Schedule Information, Claim Coding and Payment Policies

Physician fee schedules shall be made available to all contracted physicians through the Internet and can be changed only once a year.

Physicians will be provided with 90 days advance notice of all planned Material Adverse Changes to Aetna’s policies and procedures affecting performance under contracts with participating physicians.

P a y m e n t p o l i c i e s w i l l b e c o n s i s t e n t a c r o s s a l l o f A e t n a products and claim systems. s

A pre-adjudication tool on Aetna’s Web site provides informational edits on CPT code combinations so that physicians can obtain Aetna’s allowable amount in advance of the actual payment.

Certain medical payment policies, code editing policy and claims adjudication logic will be disclosed to physi- cians through Aetna’s Web site.

*CPT is a registered trademark of the American Medical Association.

© 2006 American Medical Association

Copies of contracts will be provided to physicians upon written request.

Capitation fees will be paid retroactive to the date of enrollment, when a patient chooses a primary care physician (PCP) or is assigned to the PCP.

Prompt Payment Requirements

Generally, Aetna is required to issue a check or electronic funds transfer within 15 calendar days of the receipt of clean electronic claims and within 30 calendar days of the receipt of clean paper claims.

Interest will be paid at the lesser of prime rate or 8% on delayed claims.

Paper claims will be date stamped upon receipt in the mailroom and an electronic acknowledgment will be generated when an electronic claim is received.

Overpayment Recovery

Overpayment recovery efforts will not be initiated more than 24 months after the original payment. A 30-day written notice will be provided to the physician prior to initiating an overpayment recovery effort (other than for recovery of duplicate payments).

Medically Necessary or Medical Necessity Definition Aetna accepts the following definition of medical necessity.

“Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent thera- peutic or diagnostic results as to the diagnosis or treat- ment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.


Arbitration fees for solo and small group physicians are capped at $1,000.

New Physician Credentialing

New physician group members will be credentialed within 90 days of the receipt of the application. Physicians also can submit an application prior to their employment.


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