Health Insurance Plans | Aetna



4399915-933450CodesProvider types affectedWhat’s changing30462, 30465, 35875, 35876, 36831, 58546Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 7 (AEG7)Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 7 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied30462, 30465, 35875, 35876, 36831, 58546Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 7If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? 19298, 21127, 38570, 43653, 50945, 50947, 50948, 54690, 54692, 55550, 55873, 58545, 58550Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 6 (AEG6)Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 6 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied19298, 21127, 38570, 43653, 50945, 50947, 50948, 54690, 54692, 55550, 55873, 58545, 58550Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 6If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? 44370, 44379, 49566, 52647, 52648, 52649, 58563, 62287Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 5 (AEG5)Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 5 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied44370, 44379, 49566, 52647, 52648, 52649, 58563, 62287Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 5If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? 29862, 49501, 49507, 49520, 49521, 49553, 49557, 49561, 49572, 49582, 49587Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 4 (AEG4)Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 4 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied29862, 49501, 49507, 49520, 49521, 49553, 49557, 49561, 49572, 49582, 49587Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 4If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? 29848, 29893Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)Code will remain assigned to Endoscopic procedures (ENDO) and Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Endoscopic procedure rate, there will be no changeIf contract does not contain an Endoscopic rate, but has an Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 rate, then the Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 rate will be appliedIf the contract contains neither an Endoscopic rate or an Ambulatory Surgery – Aetna Enhanced Grouper Category 3 rate, the Ambulatory Surgery: Default Rate will apply.36475, 36478, 47556, 55875Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied52282Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)Code will remain assigned to: Minor Surgery: All Surgery (MINSURDEF); Minor Surgery: Medicare Groupers (MINSURMED) and Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains any of the following rates: Minor Surgery: All Surgery; or Minor Surgery: Medicare Groupers there will be no change.If contract does not contain any of the above Minor Surgery rates but does contain an Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate, then the Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate will be appliedIf the contract contains none of the Minor surgery rates or an Ambulatory Surgery – Aetna Enhanced Grouper Category 3 rate, the Ambulatory Surgery: Default Rate will apply.58565Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)Code will remain assigned to: Surgical Hysteroscopy (HYSTERINF) and Ambulatory Surgery: Default Rate (DEFAULTSUR).If the contract contains a Surgical hysteroscopy rate, there will be no changeIf the contract does not contain a Surgical hysteroscopy rate but does contain an Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate, then the Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate will be appliedIf the contract contains neither a Surgical hysteroscopy rate or an Ambulatory Surgery – Aetna Enhanced Grouper Category 3 rate, the Ambulatory Surgery: Default Rate will apply.29848, 29893, 36475, 36478, 47556, 52282, 55875, 58565Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 3If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? 45190Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 (AEG2)Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).If the contract does not contain the above rate, the Ambulatory Surgery: Default Rate will apply.45190Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 2If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? 36476, 36479Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 1 (AEG1)Code will remain assigned to Endoscopic procedures (ENDO) and Ambulatory Surgery: Default Rate (DEFAULTSUR).If contract contains an Endoscopic procedure rate, there will be no changeIf contract does not contain the above rate, but has an Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 rate, then the Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 rate will be appliedIf the contract contains neither an Endoscopic rate nor an Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 rate, the Ambulatory Surgery: Default Rate will apply.36476, 36479Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers Will be reassigned to Coventry Enhanced Grouper: Grouper 1If not listed above, then the Undefined Procedure Rate will be applied.If the contract contains none of the above provisions, the relevant terms of the contract will rule.?? Recognition of Bill Types 142-149 for Hospital Outpatient Department (HOPD) Ambulatory Payment Classification (APC) pricing Facilities including Acute Short Term Hospitals Bill Types 142-149 will be assigned to the list of eligible bill types utilized for participating providers who are contracted with the Centers for Medicare and Medicaid (CMS) Hospital Outpatient Department (HOPD) Ambulatory Payment Classification (APC) payment methodology When contracted with the APC payment methodology, these claims will begin pricing at this method and no longer at the contracted default outpatient rate. J0640, J0641Facilities including Acute Short Term Hospitals, Free Standing Ambulatory Surgery Centers and Skilled Nursing FacilitiesWill be removed from All Other Drugs (HCDHPALLOTH). Codes will remain assigned to All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein (DEFALLDRUGS).The All Other Drug rate will no longer be applied to these codes. The existing All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein will begin to be applied.If the contract does not contain an All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein rate, the existing All Other Outpatient rate will be applied. J0640, J0641Facilities including Acute Short Term Hospitals, Free Standing Ambulatory Surgery Centers and Skilled Nursing FacilitiesWill be added to Chemotherapy Drugs (HCDHPCHEMCS, HCDHPCHEMO, and OPCHEMODRUG). If the contract contains a Chemotherapy Drug rate, then this rate will be applied. If the contract does not contain a Chemotherapy Drug rate, the All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein will continue to apply.73706, 76497Facilities including Acute Short Term Hospitals, Ambulatory Surgery Centers, Children’s Hospital , and Diagnostic Radiology CentersWill be assigned to CTSCAN (CAT Scan).Codes will remain assigned to DIAGRAD, RAD, & RADHCPC (Radiology Services). If a CAT Scan rate is present in the contract, the CAT Scan rate will be applied; if contract does not contain a CAT Scan rate, the existing Radiology Services rate will continue to apply.Drug code groupingsFacilitiesWe are NOT changing the codes contained within drug service groupings. However, we identified a system issue. To correct the issue, the formatting of these codes require an internal change. ?The following service groupings will be updated: ?Drugs (DRUGS) Chemotherapy Drugs (HCDHPCHEMCS, HCDHPCHEMO, and OPCHEMODRUG), All Other Drugs (HCDHPALLOTH).? Chemotherapy & All Other Drugs (HCDHPALL, HCDHPALLWCS).Effective 9/1/2017, we will remove any code ranges contained within these service groupings; each code will be entered individually instead.? Changes in compensation may occur, however we will not pursue any past overpayments.Not Provided (NONCNT)All Provider typesIf a contract contains a service defined as Not Provided, when that service is billed today, it is manually priced at the All Other Outpatient Default rate, or the Inpatient Medical Surgical rate, based on the claim type. Following this change, the service will no longer be priced. *Unless otherwise indicated all updates will be effective 09-01-17.Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).?2017 Aetna Inc. ................
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