Needs Review Not Apprvd
May 2017, Issue 28
Medicare Direct, aka Medicare Crossover
The AlaskaCare Retiree Health Plan becomes supplemental to Medicare Parts A and B when you or your dependent reach age 65, beginning on the first day of that month. As the supplemental plan, AlaskaCare will require information regarding what Medicare has paid on your claim before a secondary payment can be processed.
Medicare Direct is the electronic process that eliminates the need for a retiree to file a paper supplemental claim with Aetna, the AlaskaCare third party claims administrator (TPA), when Medicare Part B is primary. The Medicare carrier forwards claims automatically and electronically. Medicare Direct is sometimes referred to as Medicare Crossover.
Medicare uses a unique identifier called a Health Insurance Claim Number (HICN). The HICN for the retiree is most commonly, but not always, the 9-digit Social Security Number (SSN) followed by the letter “A,” indicating a wage earner. Aetna will automatically enroll retirees using their SSN plus the letter “A” as their Medicare number. If your Medicare number is not your SSN+, you must call Concierge Services and to let them know what your number is.
Spouses in every instance need to call Concierge Services and ask to be enrolled, as Aetna cannot assume their Medicare number. Since many spouses over age 65 may not have been wage earners, Aetna must have confirmation of an accurate Medicare number.
Enrolling a retiree in Medicare Direct has many benefits, including:
- Saving the retiree time and paperwork. The retiree will no longer have to file Part B claims to Aetna. (Note: Medicare Direct does not apply to Part A hospital claims.)
- Turnaround time is quicker, because claims come to Aetna electronically; therefore, reimbursement is quicker.
- No postage is required.
- No cost to the retiree or provider to enroll or send claims.
After Medicare Direct is in place and Medicare has considered a claim, the remaining expenses are automatically forwarded to Aetna. Your EOMB (Explanation of Medicare Benefits) will have a comment to the effect of “your claim has been forwarded to your secondary carrier for further consideration.” You will always receive an EOMB from Medicare; however, you will not receive a BILL from Medicare.
If you or your spouse become covered under another plan in addition to AlaskaCare and Medicare, please contact the AlaskaCare Concierge to notify them of the change, as it may impact your Medicare Direct participation. In addition, if you or your spouse’s Medicare number changes for any reason, Aetna will need to be notified or the Medicare Direct process will no longer work for you.
Aetna Nurse Line
Did you wake up this morning feeling just a little under the weather? Not bad enough to go to the ER, but not good enough to wait to see your doctor? Are you tired of rumbling through your medicine cabinet while your spouse rattles off a multitude of diagnoses from Google’s symptom search? You need advice from a medical professional. Why not start with the Nurse Line? It’s free and available 24/7.
Call (800) 556-1555!
Outpatient Rehabilitative Care Coverage in the AlaskaCare Retiree Health Plan
This article does not apply to the AlaskaCare Employee Health Plan. For details about coverage in the Employee Plan, see the plan document at AlaskaCare.gov.
Outpatient rehabilitative services such as chiropractic care, physical therapy, massage therapy, and occupational therapy are commonly obtained following joint replacement surgery or after suffering an injury to your back, knee, shoulder, or other joints. Coverage for these services is based on the concept of a “rehabilitative program of care,” or treatment which pairs a specific illness, injury, or surgical procedure and a care provider.
Each program of care should include:
- documentation of the illness or injury,
- an initial evaluation with objective and subjective measurements of the patient’s functionality,
- a written program of care with an expectation of improvement, and
- periodic follow-up evaluations showing continued improvement.
Every program of care will also have a point of maximum therapeutic benefit after which additional services are considered not medically necessary (i.e. maintenance therapy). After that maximum therapeutic benefit has been reached, additional treatment in that program of care, regardless of the relief from symptoms it may provide, would not be considered medically necessary by the Plan.
If you have a new injury, illness, surgery etc., to a body part or location where a prior program of care was denied coverage, the new claim would also be denied. Through the appeal process, a patient and provider would have to submit new medical records and the initial evaluation as well as any new re-evaluations, etc. to establish medical necessity and receive coverage. If you are planning an upcoming surgery or are currently utilizing the rehabilitation services benefit, it is important to understand your Plan’s requirements for coverage. This way, you will have a clear understanding of what claims for rehabilitative services would be covered by the Plan, and when Plan coverage of rehabilitative services end.
How does the Plan determine if the services are medically necessary?
The AlaskaCare claims administrator (currently Aetna) is required to verify that services are medically necessary as required by the AlaskaCare Plan document, and will request copies of your treatment records from your provider. Generally, medical review is not needed for these services if the course of treatment does not exceed 25 visits. For a new rehabilitative program of care, Aetna will typically request medical records from your provider when it receives the claim for the 20th visit in a rehabilitative program of care.
What information must my provider supply to the AlaskaCare claims administrator?
Your provider will be required to supply clinical records that contain sufficient information for the claims administrator to determine both your condition and that the associated treatment meets the policy requirements stated in the Plan document and Aetna’s applicable Clinical Policy Bulletins (available at Aetna. com/cpb). The bulletins are numbered as follows:
- 0107 for chiropractic services
- 0243 for speech therapy
- 0325 for physical therapy
The documentation submitted should include at least
- the initial evaluation and diagnosis,
- a written program of care,
- the most recent therapy re-evaluation with an updated plan of care,
- the last five daily therapy and progress notes, and
- documentation supporting the need for ongoing supervised rehabilitative care, including dates of surgery, invasive procedures, or a change of diagnosis.
The Plan provides coverage of treatment to rehabilitate the patient to a point where they have reached the optimum functional benefit that can be reasonably expected. There must be reasonable expectations that the therapy or treatment will produce significant clinically documented improvement in the patient’s body function within a reasonable period and continued improvement is expected. The AlaskaCare Plan does not cover “maintenance” care, that is, services to keep the patient in their “rehabilitated” state. Maintenance is not considered a “medically necessary service.”
What if the AlaskaCare claims administrator determines the clinical records do not support the treatment as medically necessary?
It is essential that AlaskaCare members understand that “medical necessity” in this instance requires continued significant clinically documented improvement. You may wish to review Aetna’s Clinical Policy Bulletins with your provider before you begin treatment. This will allow you and your provider to review the Plan’s criteria for determining when services and procedures are considered medically necessary. If it is determined by the AlaskaCare claims administrator that the treatment is not medically necessary, all claims after the 25th visit for that condition will be denied.
Alaska Regional Hospital: Important Information For All AlaskaCare Plans
Alaska Regional Hospital is the only hospital in the municipality of Anchorage where all the hospital-based physicians are in-network. (Hospital-based providers are anesthesiologists, radiologists, emergency room doctors, hospitalists, and pathologists.) This means there shouldn’t be any surprise balancebilling when you receive care at Alaska Regional Hospital.
Alaska Regional Hospital is an award-winning facility and offers a full range of services comparable to other full-service hospitals in Alaska. The last three years have been spent improving the facility to make it more attractive and inviting. In addition, its technology and documentation systems have had state-of-theart upgrades to support the delivery of high quality patient care. AlaskaCare’s agreement with Alaska Regional Hospital provides our members with access to high quality service, provided by your doctor, at competitive prices.
AlaskaCare Employee Health Plan
Alaska Regional Hospital is the preferred provider hospital for members of the AlaskaCare Employee Health Plan. Members are encouraged to choose the preferred hospital for facility services received in the municipality of Anchorage to avoid reduced reimbursement rates, reduced allowed charges, and increased maximum out-of-pocket costs. It is now more important than ever to use a preferred facility to avoid costly balance bills and increased cost shares. Read More here.
AlaskaCare Retiree Health Plan
The AlaskaCare Retiree Health Plan does not require members to choose a preferred provider for hospital services. While Alaska Regional Hospital is the preferred provider hospital in the Anchorage area, there will be no penalty for retired members who receive services at another facility. However, the discounts offered by Alaska Regional Hospital will help minimize costs to AlaskaCare members and to the plan. By using the preferred provider hospital, you will also help conserve and wisely use the resources of the retiree health trust. In addition, retirees can take advantage of the Senior Health Clinic and the new concierge “Josie” (see below).
Alaska Regional Hospital Senior Health Clinic
Providing Care to Alaska’s Medicare Beneficiaries
Alaska Regional Senior Health Clinic offers integrated health services to Medicare B beneficiaries in Anchorage and its surrounding communities. Here, you can see medical providers who specialize in primary care for Alaska’s Medicare beneficiaries, as well as outpatient adult medicine and mental health services.
Conditions treated include, but are not limited to:
- Acute illnesses
- Heart disease
- High blood pressure
- High cholesterol
- Other chronic disorders
Appointments are available Monday through Friday from 8 a.m. to 5 p.m. Call (907) 433-5100 to make an appointment.
Alaska Regional Hospital Health Care Concierge: "Just Ask Josie"
Have you ever wanted to meet the person behind the customer service 800 number you called at your bank or telecommunications company? Alaska Regional Hospital has done just that with its new Healthcare Concierge Department. Meet the concierge, Josie, your one-stop-shop for all Alaska Regional Hospital departments. With Josie, there’s no more calling a general phone number and having to experience multiple transfers before reaching your intended party. You now have access anytime via email. This designated confidential email has been specifically created for members of the AlaskaCare Employee and Retiree Health Plans. With just one email, you can get the information you need, or if you prefer, provide your telephone number and request to have the concierge call you. It will happen! You may also receive a personalized visit from the concierge when visiting an Alaska Regional Hospital department. Whether you or a loved one are an in-patient at Alaska Regional or utilizing one of the numerous out-patient services on campus, the concierge’s sole purpose is to help ensure that your health care experience with Alaska Regional Hospital is a good one. Specifically, the concierge acts as your interface between Alaska Regional Hospital departments to help you with patient navigation, billing questions, transfers between facilities, and directing you to in-network options to ensure AlaskaCare members are maximizing their full benefits and savings.
We are pleased to introduce you to Josie Wilson and Alaska Regional Hospital’s “Just Ask Josie” Concierge Program.
You can “Just Ask Josie” by emailing: Josie.Wilson@hcahealthcare.com.
Vitamin D is important for strong bones and may contribute to overall good health. Alaskans should select foods that are high in vitamin D, such as Alaska salmon, and should talk with their health care provider about vitamin D and the risks and benefits of supplementation.
Retiree Health Plan Dependent Eligibility Audit Has Been Postponed Until August 2017
AlaskaCare has contracted with Health Management Systems, Inc. (HMS) to conduct an audit of all currently eligible dependents. Important information on this audit will be sent to retirees starting in August 2017.
Dependent eligibility audits are performed periodically and are intended to protect the health trust by ensuring only eligible dependents are receiving benefits. Beginning in August 2017 you should receive communications from HMS outlining what documentation you will need to provide. For example, verification documents for a spouse may include copies of your marriage certificate and a current tax record or household bill that list your spouse’s name and address. Examples for dependent children include birth certificates or adoption records, and if age 19 or older, their full-time school attendance records.
In anticipation of this audit, you may wish to begin gathering copies of your documents now. Please watch your mailbox for additional information about this audit.
The information provided on this page may or may not be up-to-date. If you are unsure, please contact us.