Many of you have probably already received this from Aetna but I thought I would still pass it on. Aetna had a release last week and fixed some long standing bugs. Below is an exerpt of the announcement they sent out regarding the release.
Eligibility Transaction Changes
1. We’ll remove the following messages, which are no longer needed:
o The “Age Limit Applies” message is no longer needed, as we give the actual ages in our response when limits apply.
o The “Applies to HMO provider” message is not needed, as we no longer have a need to limit benefits specifically for HMO providers.
2. In support of Safe Harbor guidelines, which provides contraceptive supplemental coverage through a separate plan with Aetna listed as the plan sponsor, we’ll:
o Issue two Member ID cards, one for the base medical plan and one for the supplemental contraceptive coverage plan.
o Return a message within the eligibility transaction to direct providers to the appropriate plan when necessary to obtain benefits.
3. We’ll add a message when some Not Covered responses are returned.
Benefits may be available. Please inquire under member’s medical plan
Please inquire under member’s medical plan
Member does not fall within the age limitations for this benefit
4. We’ll correct the following items:
- Currently some HMO benefits are incorrectly returning as NOT COVERED. We’ll implement a fix, so that our responses will correctly show the benefits are covered when applicable.
- Currently, we’re returning plan level benefits and limitations even when patients are outside of the age range for the service. We’ll implement a fix to send a message with a Not Covered response.
Electronic Remittance Advice (835):
In preparation for ERA certification under Health Care reform, we’ll make the following changes and quality improvements:
- We’ll fix numerous causes of out of balance (OOB) at the payment, claim and service levels. This should significantly reduce overall occurrences of OOB ERAs.
- For a small number of remaining OOB claims, those adjudicated on the strategic platform (ACAS) will be placed in their own payment groups rather than being grouped with other, balanced claims. It’s expected that isolating OOB claims into their own groups (one claim per group) will make reconciliation easier if a provider needs to reconcile OOB claims manually.
- When we deny a claim submitted as primary because Aetna is secondary and the primary payer is Medicare, currently we fail to send the indication that the primary payer is Medicare (2100:NM1*PR segment). In this release, we’ll fix a cause of this omission.
- We’ll correct several issues in HMO and Aeppays that result in HMO ERAs dropping to paper EOBs. Claims not found in Enterprise Claim Repository will also no longer be grouped with ‘good’ claims. After the August release, there should be a decrease in volume of ERAs dropping to paper EOBs, and the ERAs that do drop to paper will only contain one or a small number of ‘bad’ claims.