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Retiree Health Plan General Questions

Disclaimer: The below information is provided for informational purposes. In the event of a conflict between the below information and the AlaskaCare Plan Document, the plan document controls.


General

  1. Why have I received two ID cards?
  2. To improve our network and customer service, AlaskaCare selected Aetna to administer all medical and pharmacy claims and Moda Health to administer all dental claims. In the past, these services had been provided by a single company. You should have received a medical ID card from Aetna and a dental ID card from Moda to use when visiting your health care provider or pharmacy.

  3. My ID card hasn’t arrived, what should I do?
  4. Medical/Rx ID Card

    If your ID card hasn’t arrived, you can view and print your Medical/Prescription ID card or download the mobile app that displays the ID card on your smartphone. Note: Aetna Navigator registration required.

    You can use your Social Security number to register or call the Aetna health concierge (855) 784-8646 for assistance.

    Dental ID Card

    To print your Moda Health/Delta Dental of Alaska ID card or download the MyModa mobile app, register on the MyModa Web site or call Moda at (855) 718-1768.

  5. How do I install the iTriage app on my mobile device?
    1. Download or update the free iTriage App from your App store/Google Play Store
    2. Create a "MyiTriage" account (found in the lower left of the standard app)
    3. Choose "My Insurance" and then select "Aetna" as your insurance carrier.
    4. Enter your Aetna Member ID and Group Number as they appear on your ID card. If entered correctly, Member ID and Group Number will be validated
    5. Select “Link Aetna Navigator Account” and add your Aetna Navigator login and password*

    *If you don’t already have an Aetna Navigator account, you will be able to create one on this page.

  6. Why isn’t preventive care covered by my AlaskaCare Retiree Health Plan?
  7. Preventive care was not part of the original benefits covered by the AlaskaCare Retiree plan when it was created in 1975. The Division of Retirement and Benefits understands that there is strong interest in adding these benefits to the retiree health plan and is exploring options to do so while remaining cost neutral.

  8. Why aren’t dependents covered to age 26 under the Retiree health plan?
  9. The rule requiring health plans to extend dependent coverage up to age 26, regardless of financial dependency, student status, employment or marital status, doesn't apply to AlaskaCare retiree health benefits because the plan is exempt from Affordable Care Act requirements. The Division of Retirement and Benefits understands that there is strong interest in adding these benefits to the retiree health plan and is exploring options to do so while remaining cost neutral.

  10. What is recognized charge?
  11. A recognized charge is the maximum amount that AlaskaCare’s Medical, Vision and Audio plans will pay for a covered service. The term recognized charge is sometimes referred to as the usual, customary and reasonable (UCR ) charge or the maximum allowed charge.

    An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is sometimes referred to as balance billing.

    When you use a network provider, you are not subject to balance billing for covered services. In other words, the provider has agreed to accept, as payment in full, the recognized charge for the service provided. You are only responsible for payment of other applicable charges such as deductibles, co-insurance, and/or non-covered charges.

    The recognized charge is the lesser of:

    • The amount the provider bills, or
    • The 90th percentile of the prevailing charge rate for the geographic area where the service is furnished. The 90th percentile of the prevailing charge rate means the charge that is at or below 90% for all of the charges reported for a service within a specific geographic area.
  12. How is the recognized charge amount determined?
  13. The recognized charge for out-of-network providers is the 90th percentile of the prevailing charge rate for the geographic area where the service is furnished. The AlaskaCare plans establish the percentile (i.e., 90th percentile) to be applied to the prevailing charge rate; however, the prevailing charge rate is reported by FAIR Health, an independent not-for-profit corporation. FAIR Health collects charge data from claims received by insurance plans and health plan administrators across the country for charges billed by physicians, hospitals and other healthcare providers. Charges reported are the full fees that healthcare professionals report to insurers as part of the claims process—not the negotiated rates that apply when visiting a network provider. Charges reported are maintained by FAIR Health in its database which is comprised of billions of claims for billed medical procedures from across the United States. New charge data are continually added to the FAIR Health database.

  14. How does the plan know that FAIR Health’s information is reliable?
  15. FAIR Health has audit and validation programs in place to ensure the integrity of its data. Part of the validation process entails testing the data with statistical algorithms and examination by FAIR Health’s in-house statistical and technology experts. A team of healthcare researchers from leading academic institutions advise FAIR Health on the best methods for analyzing its national claims data. FAIR Health is also advised by an independent Scientific Advisory Board of prominent researchers who review Fair Health’s statistical methods and data. FAIR Health also seeks input from other stakeholders such as consumer and patient advocacy groups, healthcare providers, actuaries and federal officials.

  16. How are the services identified in the FAIR Health database?
  17. Each specific service, procedure or supply in the FAIR Health database has a unique Current Procedural Terminology (CPT) code. CPT codes are numbers assigned to medical services and procedures. CPT codes are part of a uniform system of coding maintained by the American Medical Association and are used by providers, facilities and insurers. Each CPT code is unique. There are currently over 10,000 medical services and procedures classified by CPT code. Most CPT codes are very specific. For example, the CPT code for a 15-minute office visit is different from the CPT code for a 30-minute office visit.

  18. How are the geographical areas determined?
  19. FAIR Health organizes its data by geozip—geographical area usually defined by the first three digits of the U.S. zip codes. Geozips may include areas defined by one three-digit zip code or a group of three-digit zip codes. Geozips generally do not include zip codes in different states. The State of Alaska is currently defined into three geozips:

    • 995 and 997—including Anchorage, Bethel, Fairbanks, Kotzebue, etc…
    • 996 and 998—including Homer, Kodiak, Juneau, Sitka, etc…
    • 999—including Ketchikan, Prince of Wales, Wrangell, etc…
  20. What if there are not enough occurrences of a procedure in a particular geozip?
  21. If there are fewer than nine occurrences of a procedure in a geographic area, the plan uses FAIR Health’s "derived charge data" instead. This data is based on the charges for comparable services, multiplied by a factor that takes into account the relative complexity of the service. If this information cannot be obtained locally, then national data is used.

  22. What factors can affect the recognized charge?
  23. The following factors can affect the recognized charge:

    • Billing errors: when a provider makes a mistake on either the procedure code or zip code.
    • Multiple procedures: when a provider performs multiple surgical procedures during a single session. The standard practice in such cases is to bill 100% for the primary (largest) procedure, 50% for the secondary procedure and 25% for all others. However, incidental items that require little or no additional time should not have an additional fee.
    • Unbundling: when a provider shows separate codes on the bill for related or incidental services. For example, instead of being billed separately, related blood tests performed at the same time should be billed under a single General Health Panel code.
  24. How can I make sure an out-of--network provider’s rate will be within the recognized charge?
  25. You can verify whether an out-of-network provider’s charges are within the recognized charge by calling the Aetna Concierge and providing the following information: (1) the procedure code, (2) the zip code where the service is to be performed, and (3) the projected cost. Aetna will use this information to estimate whether the proposed amount is within the recognized charge. Remember, if you use an Aetna network provider, those providers have already contracted with Aetna to offer discounted fees and those discounted fees are deemed to be within the recognized charge.

  26. When I use an out-of -network provider, how much of the bill am I responsible for?
  27. If you use an out-of-network provider, you are responsible for the difference between the recognized charge and the amount charged by the provider in addition to other applicable charges such as deductibles, co-payments, co-insurance and non-covered charges.

  28. What should I do if my out-of-network provider charges more than the recognized charge?
  29. If the out-of-network provider’s claim exceeds the recognized charge, and you have already paid your out-of-network cost-sharing amount, wait for the provider to send you a bill, since the out-of-network provider may adjust their charges after reviewing the claim payment. If not, ask the out-of-network provider to:

    1. Consider reducing or waiving their fee to meet the recognized charge amount;
    2. Review the bill to ensure the correct procedure code and amount was used (and if not, submit a corrected bill to the plan);
    3. Confirm that the out-of-network provider charged their normal fee for the service, or if the out-of-network provider increased the charge due to unusual circumstances. If so, ask the out-of-network provider to either submit a corrected bill to the plan or provide a written explanation so you may file an appeal with the plan.
  30. Is the recognized charges provision a change?
  31. No, the plan has always determined claims payment based upon the recognized charge. Prior to January 1, 2014, AlaskaCare plan documents referred to the recognized charge as the "usual, customary and reasonable (UCR) charge or the “maximum allowed charge."

  32. As our claims administrator, what are Aetna’s policies for claims reimbursement?
  33. Aetna’s claim reimbursement policies address the appropriate billing of services, taking into account factors that are relevant to the cost of the service such as:

    • The duration and complexity of a service;
    • Whether multiple procedures are billed at the same time, but no additional overhead is required;
    • Whether an assistant surgeon is involved and necessary for the service;
    • Whether follow up care is included in the price of the service;
    • Whether there are any other characteristics that may modify or make a particular service unique; or
    • When a charge includes more than one claim line, whether any service described by a claim line is part of or incidental to the primary service provided.

    These claim reimbursement policies are based on:

    • Policies developed for Medicare;
    • Peer-reviewed, published medical journals;
    • Available studies on a particular topic;
    • Evidence-based consensus statements;
    • Expert opinions of health care professionals;
    • Guidelines from nationally recognized health care organizations.
  34. When I use an out-of -network provider, how much of the bill am I responsible for?
  35. If you use an out-of-network provider, you are responsible for the difference between the recognized charge and the amount charged by the provider in addition to other applicable charges such as deductibles, co-payments, co-insurance and non-covered charges.

  36. How can I appeal a recognized charge determination for an out-of-network provider?
  37. You may appeal a recognized charge determination by providing additional information to indicate why the recognized charge was not correct, such as incorrect procedure codes, an incorrect zip code, etc. Information on appealing claim decisions is available in the AlaskaCare plan documents.

  38. Where can I get more information about recognized charges?
  39. Specific plan language regarding recognized charges is available in the January 1, 2014, AlaskaCare Retiree Health Plan Amendment on pages 16 through 18 and in the AlaskaCare Employee Health Plan on pages 187 through 189.

  40. How do I avoid recognized charge issues?
  41. See a network provider if one is available. When you see a network provider, the plan will pay based on the lesser of the billed amount or the provider’s discounted fee amount.

Network

  1. I’m a retiree; why should I use a network provider?
  2. Using “network” providers can provide substantial benefits to members through the elimination of what’s known as “balance billing.” It can also generate substantial savings to members through negotiated provider discounts. To find out whether your doctor is a member of the Aetna network, call Aetna's Health Concierge at (855) 784-8646 or select the "Find a Doctor" button on our Web site at AlaskaCare.gov. To find out whether your dentist is a member of the Moda/Delta Dental network call Moda/Delta Dental at (855) 718-1768 or select the “Find a Dentist” button on our website.

  3. What is balance billing?
  4. The AlaskaCare plans limit payment of covered services to the recognized charge. The recognized charge is the maximum amount the AlaskaCare plans will pay for a covered service. Aetna and Moda/Delta Dental, and their respective network providers (sometimes referred to as participating providers), agree to a set of discounted negotiated rates for services provided. The recognized charge for network providers is the negotiated rate. For an explanation of how the recognized charge is calculated for out-of-network providers, please see the recognized charge questions under the Network and Dental sections.

    An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is often referred to as balance billing. Network providers have agreed to accept, as payment in full, the negotiated charge. Therefore, you are not subject to balance billing when you use a network provider.

  5. If I have a procedure or service at a network facility, can I be balance billed?
  6. You may find that not all providers at a “network” facility are part of the Aetna network. For example, if you have a surgical procedure performed at a network hospital, you may find that the hospital and surgeon are in the network, but the anesthesiologist is out-of-network. When you get your bill, you’ll see that it reflects the negotiated network rates for your hospital and surgeon. The anesthesiologist, however, may charge what s/he chooses since s/he has no negotiated contract with Aetna. If the anesthesiologist claim exceeds the recognized charge, you may receive a bill for the balance.

  7. How do I avoid receiving a balance bill?
  8. You may prevent balance billing by verifying all medical providers are in the Aetna network and making sure your AlaskaCare Plan covers the services you need. For example, if you’re having x-rays, MRIs, CT scans, or PET scans, make sure both the imaging facility and the radiologist who will read your scan are in the network. If you’re planning surgery, ask whether the anesthesiologists are in the network. If available, the facility should accommodate your request to use a network provider for your services.

    Similarly, for AlaskaCare covered dental services, you may prevent balance billing by verifying the provider is in the Moda/Delta Dental network.

  9. What if there is no network provider available?
  10. If your provider is not a network provider, you may ask for an estimate of charges, the codes that will be used use for billing, and the provider’s zip code. When you receive this information, contact the Aetna Concierge at (855) 784-8646 or Moda/Delta Dental at (855) 718-1768. A member of the Aetna Concierge or Moda Customer Service team can review the estimated charges and will advise you if the charges fall within the recognized charge for your area. If the estimated charges exceed the recognized charge, you may request that your provider accept that amount and not balance bill you, or you may request payment arrangements with their office.

    If your current provider is not listed as a network provider, you can ask your provider to contact Aetna at (800) 720-4009 or Moda at (855) 718-1768 for a participation application. Members are also encouraged to nominate their out-of-network providers to join the network. Contact the Aetna Concierge or Moda Customer Service to find out how.

    In some cases, unfortunately, there will not be a network provider for the service you need in your area. The Division, Aetna and Moda/Delta Dental are working diligently to improve network access, but please understand that we cannot force providers into the network.

  11. Is there a “network” for durable medical equipment (DME)?
  12. Aetna does have a DME national provider listing on their DocFind website. To get the current listing, go to =AlaskaCare.gov and select the Find a Doctor tool. In DocFind under the “Search by Location” tab, use the “Search for:” drop down menu to select Other (X-ray, Surg Ctrs; Med Equip, etc.) and the “Type:” drop down menu to select Durable Medical Equipment-National.

    For local DME providers, change the “Type:” to Durable Medical Equipment-Local and enter the appropriate zip code and plan.

Affordable Care Act

  1. How will the Cadillac tax affect me?
  2. Only those health plans that cost more than $10,200 per year for an individual and $27,500 per year for a family will potentially be impacted by the tax.

    The AlaskaCare Retiree health plan is not exempt from the Cadillac tax. Based on the current valuation, our benefits consultants estimate that the retiree plan would not meet the Cadillac tax threshold until 2038.

    Dental, Vision, Long Term Care (LTC), accident/disability, and fixed indemnity plans paid with post-tax dollars are excluded from the Cadillac tax calculations. Retiree Dental, Vision and LTC premiums are paid with post-tax dollars, and are therefore excluded.

Medicare

  1. Why do I need to purchase Medicare Part B?
  2. The AlaskaCare Retiree health plan was created by statute to provide health coverage to eligible retirees and their dependents in 1975. Alaska Statute Sec. 39.35.535(b) requires that the retiree health plan become supplemental to federal old age benefits available at age 65. This statute has been in effect since 1975. The Retiree Insurance Information Booklet section titled, "Effect of Medicare", states: “If you do not enroll in Medicare coverage the estimated amount Medicare would have paid will be deducted from your claim before processing by this plan.”

  3. Do I need to get Medicare part D?
  4. You are not required to enroll in Medicare Part D as the drug coverage benefits you have through your AlaskaCare Retiree plan are at least as good as the required benefits offered under Medicare Part D. By not enrolling in Part D, you can avoid unnecessary premiums and coordination between Medicare and AlaskaCare for your prescription drugs.

  5. Do I need to get Medicare part C?
  6. You are not required to take part in Medicare part C. Part C plans are Medicare Advantage plans provided by private insurers for members who live outside the State of Alaska. They cover the same services as Medicare Part A and B combined as well as some supplemental benefits. The AlaskaCare plan acts as a supplemental plan for Medicare eligible retirees.

Vision

  1. Why has my vision claim been denied?
  2. Many retirees have reported that Aetna denied their vision claims in error. Over the past few months, Aetna completed a thorough review of AlaskaCare vision claims and identified a few issues, which, at this point should be resolved. Here’s what happened:

    • Aetna asked some members to provide a Medicare Explanation of Benefits (EOB) document to support a routine vision claim. AlaskaCare is the primary payer for routine vision benefits—a Medicare EOB should not be needed. Be sure to note that Medicare does cover certain vision exams (for example, glaucoma screenings for people with diabetes). When you receive these services, Aetna may contact you to request a Medicare EOB.
    • Vision Claims Denied as Not Covered. Aetna erroneously denied some members’ vision services. Aetna updated its claims system mid-May and has reprocessed impacted claims retroactive to January 1, 2014.
  3. What should I do if my provider tells me I don't have vision coverage but I know I do?
  4. Providers may receive incorrect information when verifying your vision benefits through Aetna’s self-service tool. While Aetna continues to update its systems, you can call the Aetna Concierge at (855) 784-8646 to verify your vision benefits.

  5. How do I find a network vision provider?
  6. The AlaskaCare Retiree Vision Plan does not have a network. This means you may choose to see any provider and receive plan benefits for covered services.

  7. Is my provider required to submit my claims for me?
  8. No, you are responsible for submitting your vision claims to Aetna for processing. Your provider may be willing to file the claim for you, but it is the member’s responsibility. View the Vision Benefits Claim form [PDF 597K]...

  9. What should I do if I am only enrolled in the AlaskaCare dental-vision-audio plan (but not the medical plan) and do not have an ID card to show my provider?
  10. For the AlaskaCare Retiree Vision and Audio Plans, you may print an ID card that includes your name and Aetna ID number by logging on to Aetna’s online Navigator tool and clicking “Get an ID Card.” If you are not registered for Aetna Navigator, you may call Aetna Concierge at (855) 784-8646 to obtain your Aetna ID number to give your provider.

    For the AlaskaCare Retiree Dental Plan, Moda Health/Delta Dental will send you an ID card for your dental services. If you need assistance with your dental cards, please contact their Customer Service Center at (855) 718-1768.

  11. What is VSP?
  12. The Vision Services Plan (VSP) is the vision plan currently provided under the AlaskaCare Employee Health Plan. The VSP is currently not available under the retiree plan. The VSP has a similar benefit structure to our existing retiree vision plan, and offers discounts and exclusive savings to our members. The VSP vision network has over 63,000 access points across the country, including retail outlets, such as Costco and Walmart. Under VSP, members have the freedom to choose any eye care provider, but your benefits may differ from the coverage you receive with a VSP doctor. We have received requests to consider VSP for inclusion under the retiree plan and we are evaluating the feasibility of this plan for AlaskaCare retirees. Read more...

Dental

  1. Is nitrous oxide covered by my dental plan?
  2. After talking to our members, we have added coverage for nitrous oxide to the dental plan. This change is retroactive to January 1, 2014. Denied claims were automatically reprocessed. If you have had a claim for nitrous oxide denied and have not received a revised Explanation of Benefits, please contact Moda/Delta Dental at (855) 718-1768.

  3. Why are cleanings limited to once every six months?
  4. Some of our members have advised us of scheduling challenges when making appointments, especially for those members that have to travel to see a dentist. To address this issue, we have changed the frequency for exams and cleanings from once every 6 months, to twice per benefit year.

  5. What if my health condition makes more frequent cleanings necessary?
  6. Recognizing that some members may need more frequent cleanings, we have increased the frequency limits in some cases. Your dental professional can contact Moda/Delta Dental to determine if cleanings in excess of the following limits can be approved.

    • Two cleanings per year, under normal circumstances.
    • Up to three cleanings per year for pregnancy.
    • Up to four cleanings per year for diabetes or periodontal disease.
    • Additional cleanings are available when dentally or medically necessary with Moda/Delta Dental of Alaska priorapproval.
  7. What is the dental plan recognized charge?
  8. The AlaskaCare Dental Plans limit payment of covered services to the recognized charge.

    An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is sometimes referred to as balance billing.

    When you use a Delta Dental network provider, you are not subject to balance billing for covered services. In other words, the provider has agreed to accept, as payment in full, the recognized charge for the service provided. You are only responsible for payment of applicable deductibles, co-insurance and/or non-covered charges.

    The recognized charge is the maximum amount the AlaskaCare Dental Plans will pay for a covered service.

    The recognized charge for each service or supply provided by a network provider in Alaska is the lesser of:

    • 100% of the covered expense;
    • 100% of the provider’s accepted filed fee with Delta Dental; or
    • 100% of the provider’s billed charge.

    The recognized charge for out-of-network providers in Alaska is the lesser of:

    • The provider’s billed charge; or
    • 75% of the 80th percentile of the prevailing charge rate as determined by Delta Dental.

    The recognized charge for out-of-network providers outside Alaska is the lesser of:

    • The provider’s billed charge; or
    • the prevailing charge rate as determined by Delta Dental.
  9. How is recognized charge determined in Alaska?
  10. Delta Dental of Alaska maintains a database of billed charges from its adjudicated claims in Alaska. The 80th percentile is calculated for every American Dental Association (ADA) procedure code using a statistically valid methodology, which removes outlier charges. This calculation is based on the most recent 12 months of processed claims and serves as the starting point for determining updates to the prevailing charges.

  11. How is the prevailing charge determined in Alaska?
  12. Delta Dental of Alaska incorporates a number of additional processes in order to validate the results of the 80th percentile calculation before making changes to the prevailing charges:

    1. The 80th percentile is determined statewide in order to maximize the statistical significance of the calculation.
    2. Additional data sources are compared to the results of the 80th percentile calculation for consistency purposes. Other data sources reviewed by Delta Dental are:
      • The Delta Dental Submitted Charges Database (DSC): This dataset is maintained by Delta Dental nationally and includes submitted charges from all Delta Plans for services rendered in Alaska.
      • The rates reported by Fair Health, an independent non-profit corporation.
      • Market research on prevailing charges used by other insurance carriers.
    3. c) For each procedure code, the current prevailing charge is compared to the 80th percentile calculation. Any changes to the current prevailing charge indicated by the 80th percentile calculation must be consistent with the other data sources referenced above. For new procedure codes, or those where there are too few procedures for a statistically valid 80th percentile calculation, additional considerations taken into account are:
      • The complexity of the service or supply.
      • The degree of skill needed, and
      • The cost of any materials required for the service.
    4. When a change in the prevailing charge is indicated, the change is limited to maximum percentage change unless otherwise indicated.
  13. Is this same 80th percentile calculation used for specialists?
  14. If the service provided by the specialist is exactly the same as that provided by the general dentist, the prevailing charge is the same for both (e.g. full mouth X-rays). However, if the services provided are specific to a specialist's training, the specialist will be reimbursed at a higher prevailing charge.

  15. How does the prevailing charge rate determination differ outside of Alaska?
  16. The prevailing charge is determined by Delta Dental methodology for each individual state. If you are receiving services at an out-of-network provider outside of Alaska, please contact Moda Health/Delta Dental at (888) 718-1768 for more details.

Medical Necessity

  1. What is “medical necessity?”
  2. Medical necessity is one factor the AlaskaCare health plans consider in determining whether to provide coverage for a service or supply. The AlaskaCare health plans do not pay for services or supplies that are not medically necessary, such as cosmetic procedures.

    The AlaskaCare medical plans use Aetna’s current Medical and Pharmacy Clinical Policy Bulletins to determine medical necessity. Access the bulletins...

    Determinations of medical necessity for dental procedures are made by Moda Health.

  3. How does Aetna determine if a service or supply is medically necessary?
  4. Aetna’s clinical policy bulletins are based on:

    • Reports in published, peer-reviewed medical literature
    • Studies on a particular topic
    • Evidence-based consensus statements
    • Expert opinions of health care professionals
    • Guidelines published by nationally recognized health care organizations that include supporting scientific data
  5. Are there any limitations as to what kinds of services and supplies can be considered medically necessary?
  6. Under the AlaskaCare plans, services or supplies are never considered medically necessary if they:

    • Do not require the technical skills of health care professionals who are acting within the scope of their license
    • Are provided mainly for the personal comfort or convenience of you, your family, anyone who cares for you, a health care provider, or a health care facility
    • Are provided only because you are in the hospital on a day when you could safely and adequately be diagnosed or treated elsewhere, or
    • Are provided only because of where you are receiving the service or supply, if it can be provided in a doctor’s or dentist’s office or other less costly place.
  7. If a service or supply fits the definition of medical necessity, is it always covered by the plan?
  8. No, not all medically necessary services or supplies are covered by a health plan. For example, a medically necessary service or supply is not covered by the AlaskaCare plans when:

    • It is specifically excluded, or
    • The duration of the medically necessary service reaches a plan limitation (for example, some benefits are limited to a certain number of days or visits).
  9. Shouldn’t medical necessity be defined by the plan document, and not the Third-Party Administrator?
  10. The number of medically necessary procedures and unique circumstances of their application, are virtually limitless. Thus, it is simply not feasible to produce a plan document that can account for every scenario.

    Determinations of medical necessity are part of the claims processing function. Because AlaskaCare contracts with a Third-Party Administrator (TPA) to perform this function, it is the TPA who makes determinations of medical necessity as part of the claims processing function. This is not new. Prior TPAs also made medical necessity determinations as part of the claims processing function for the AlaskaCare plans. What is new is the publication of the data used by the TPA to make medical necessity determinations. This information is now available to AlaskaCare plan members through Aetna’s contract with the State.

    The clinical policy bulletins provided by Aetna set guidelines that are transparent to members and their physicians, and clearly show the medical evidence relied upon to make the determination. The evidence basis of the policy bulletins are reviewed regularly and the bulletins are updated as necessary. Medical providers can also request peer-to-peer review with a TPA medical director to present additional medical evidence for consideration.

  11. If my doctor recommended the treatment isn’t that enough to support medical necessity?
  12. The National Institute of Health estimates that nearly 30% of all medical procedures or services performed in the United States are either unnecessary and provide no benefit to the patient, or even worse, are harmful. Aetna’s clinical policy bulletins rely on medical evidence to make decisions about coverage that are weighed against clinically accepted standards of medical practice.

    We encourage you to have your doctor review the clinical policy bulletins used to guide coverage decisions related to medical necessity. After your provider completes this review, and if they disagree, your provider may request a pre-determination of coverage and present additional medical evidence for consideration during the pre-determination review.

    To review your doctor’s recommended treatment plan, and verify whether the services or supplies fit the definition of medical necessity, contact Moda Health at (855) 718-1768 for services covered under the dental plan, or contact the Aetna Concierge at (855) 784-8646 for services covered under the medical plan.

    If there continues to be a difference in opinion, you or your provider are encouraged to appeal the coverage decision.

  13. What can I do if a claim is denied because the third-party administrator determined my service is not medically necessary?
  14. If a claim is denied based on a medical necessity, you may request an explanation of the scientific or clinical judgment for the determination, free of charge.

    If you believe it’s warranted, you may also initiate written appeal to the plan. The Employee Plan Booklet and the Retiree Plan Amendment describe the process and timeline required for submitting an appeal.

    Effective January 1, 2014, the appeals process use by AlaskaCare was enhanced to allow for the use of Independent Review Organizations (IRO) at level 2 of the appeals process. Use of an IRO allows for an impartial review by a third-party medical expert when there is disagreement regarding medical necessity

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