The latest news from the Benefits Office
Aetna Coverage Clarification/Update
- Preventative Screenings — Colonoscopies — Pursuant to Aetna’s guidelines, in-network routine colonoscopies should be considered a preventative screening and should not be subject to copayment/coinsurance.However, you should be aware, if the surgeon’s office bills the procedure as diagnostic then the claim will be paid as an outpatient surgery. You will be responsible for your deductible and coinsurance. (Your surgeon may bill the procedure as diagnostic if a polyp is found and removed or other abnormalities are discovered.)If you have had a preventative screening such as a routine colonoscopy and you believe your claim was not paid pursuant to Aetna’s guidelines, you should contact your provider to determine how the procedure was billed and if it was billed as a routine/preventative screening. If the procedure should have been billed as routine/preventative, you should ask your provider to resubmit the claim to Aetna. If you need additional assistance, you may contact Human Resources who can work with Aetna to determine how the claim was submitted (diagnosis), and if the claim was paid appropriately.We recommend discussing this procedure with your physician, in advance. Make sure your physician is aware that preventative screenings are paid at 100%. You may want to ask your physician how the claim is likely to be billed, especially if the surgeon discovers a polyp or other abnormality. Please note, if the surgeon’s office bills the procedure as diagnostic instead of preventative, Aetna must pay the claim as billed.
- Pre-certification of procedures. Pursuant to Aetna’s guidelines, some procedures must be pre-certified to ensure the claim will be paid. In general, all inpatient, mental health and most diagnostic procedures require pre-certification. Outpatient high end radiology procedures (including MRIs, MRAs, CT and PET scans) require pre-certification.If you have any questions regarding pre-certifications, you may contact Aetna. Aetna will let you know whether the provider has obtained a pre-certification. If the pre-certification is your responsibility, Aetna will work with you to obtain one.
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Children’s Health Insurance Program Reauthorization Act
On February 4, 2009, President Obama signed the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. The purpose of this Act is to provide funding for children’s health insurance under Medicaid and State children’s health (CHIP). The law also adds a new HIPAA special enrollment period.
Effective April 1, 2009, the Truman State University Health Insurance Plan has been modified to comply with the requirements of the Children’s Health Insurance Program Reauthorization Act of 2009. The notice below updates our HIPAA Special Enrollment Notice to comply with the new law.