Learn More. The Peer-to-Peer request must be received by Maryland Amerigroup maryland prior authorization Care within two 2 business days of the initial notification of the denial. The intent of the Peer-to-Peer is to discuss the denial decision with the ordering clinician or attending physician. For specific details prioe authorization requirements, please refer to our Quick Reference Guide. Certain carefirst mental providers require prior authorization regardless of place of service.
In case of a conflict between your plan documents and this information, the plan documents will govern. Working with us. Join our network. Confirm patient eligibility Precertification lists and CPT code search. Existing health care professionals. Availity provider portal Update your data Utilization management Provider referral directory. Electronic claims. Disputes and appeals. Cost estimator and fee schedules.
Pharmacy claims. Dental claims. Pharmacy services. Update pharmacy data. Find prescription drug coverage. Clinical policy bulletins. Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins.
Medicare resources. Education, trainings and manuals. Overview Educational webinars Provider manuals Behavioral health trainings. State regulations Federal regulations. News and Insights. OfficeLink updates newsletter. Company news. Existing health care professionals Availity provider portal Update your data Utilization management Provider referral directory. Pharmacy Pharmacy services Update pharmacy data Find prescription drug coverage. Resources Clinical policy bulletins Clinical policy bulletins Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins.
Education, trainings and manuals Overview Educational webinars Provider manuals Behavioral health trainings. Regulations State regulations Federal regulations. Digital authorization status letters PDF Clinical questionnaire When you submit a prior authorization request for certain services, we may pend your request for additional clinical information.
All the tools you need, all in one place. All the tools you need, all in one place The Aetna provider portal on Availity helps you spend less time on administration so you can focus more on patient care. You get a one-stop portal to quickly perform key functions you do every day You can: Submit claims Get authorizations and referrals Check patient benefits and eligibility Upload medical records and supporting documentation File disputes and appeals Update your information You can also stay up to date with the latest applications, resources and news from us.
How to get started. How to get started If your practice already uses Availity, simply contact your Availity administrator to request a username. Set up Availity account Need help registering for Availity?
Browse tips, webinars and training to get on board. Availity registration resources. Working with Aetna educational webinars. Register for a live webinar.
Availity portal resources and educational materials. Refer to these helpful resources to better navigate Aetna functionality on Availity. Need help? Legal notices Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates Aetna.
Health benefits and health insurance plans contain exclusions and limitations. See all legal notices. You are now being directed to the AMA site Links to various non-Aetna sites are provided for your convenience only.
You are now being directed to the Give an Hour site Links to various non-Aetna sites are provided for your convenience only.
You are now being directed to the CDC site Links to various non-Aetna sites are provided for your convenience only. You are now being directed to the CVS Health site. You are now being directed to the Apple. You are now being directed to the US Department of Health and Human Services site Links to various non-Aetna sites are provided for your convenience only.
Login Please log in to your secure account to get what you need. You are now leaving the Aetna Medicare website. Error or missing data. Please check your entries for an error message. This search uses the five-tier version of this plan Each main plan type has more than one subtype. I Accept. I accept. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage.
It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. Not all plans are offered in all service areas. All services deemed "never effective" are excluded from coverage. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment.
Visit the secure website, available through www. CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool.
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc.
Disclaimer of Warranties and Liabilities. Treating providers are solely responsible for dental advice and treatment of members. While the Dental Clinical Policy Bulletins DCPBs are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins DCPBs describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information.
Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered i. Your benefits plan determines coverage. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. Since Dental Clinical Policy Bulletins DCPBs can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
Click on the "Register" option in the left hand menu or the "Easy as Register Now" button at the top right of the screen. Before you register you will need the following information:. Primary Controlling Authority PCA — This person has legal authority to sign agreements for your organization and, typically, is an owner or senior partner.
Availity will work with this person should any legal or policy questions arise. Primary Access Administrator PAA — This person is legally responsible for verifying staff identities and roles, assigning Availity access to staff as appropriate to role, and maintaining user access and information. This person is typically an office or department manager or administrator and is appointed by the PCA, although the PCA may take on this role if desired.
Once the information on the registration form is verified for completeness and accuracy, Availity will notify the Organization via e-mail to the Primary Access Administrator PAA that access to the Availity portal is now available and will provide a temporary password. This process usually takes between two to three business days. Availity offers a suite of services via a single secure provider portal connection such as real-time and EDI batch transactions, including eligibility and benefits, claim status, claim submission, electronic remittance and authorizations and referrals.
Blue Cross and Blue Shield of Texas eligibility and benefits and claim status will be available this fall. At that time, access to all other Blue plans will also be made available.
The following technical requirements ensure a secure information infrastructure and a user-friendly Availity experience:. There are no set-up fees or monthly fees. Availity is free to providers for claim submission, eligibility and benefits, claim status, authorizations and referrals and remittance for commercial payers.
Additional optional services may be available at a charge if you wish to use them. Availity chooses not to charge the providers. No, all you need is a computer and a high speed connection to the Internet. Availity supports integration with most major practice management system vendors as well.
Availity understands the impact HIPAA continues to have on your organization and has taken the following steps to demonstrate our commitment to assisting you:. Participation in leadership roles in regional and national HIPAA workgroups and other health care forums. To upload a batch of claims on the portal:. Availity supports claims for hundreds of payers at no charge to you. Additional information can be located on the Availity Website.
For your protection, passwords expire every 60 days, after which you are prompted to change it. You can also reset your own password at any time. You must know the answer to your secret prompt question to change your password.
Why can't I use e-mail self-service to retrieve my user ID or reset my password? After you submit an e-mail address—via the My Info section of the My Account page or the pop-up style window that displays when you first log in—Availity sends you an e-mail verification message. You must click the link in this message within 24 hours to verify your e-mail address and enable e-mail self service.
Note: You may see an e-mail address for your account, but still not be able to use e-mail self-service. This can happen if your administrator submitted an e-mail address for you during user set-up, but you did not submit your e-mail address in the pop-up style window that displayed when you first logged in to Availity Portal.
Within 24hours, click the link in the e-mail verification message you receive from Availity. Within 24 hours, click the link in the e-mail verification message you receive from Availity. Why am I locked out of Availity Portal? Once you have logged back in to Availity Portal, enter your code to complete the 2-stepauthentication process to gain full access.
If you cannot use the on-screen options that are presented to you to unlock your account, contact your administrator. I'm a new Availity user and my temporary password has expired. What should I do? All temporary, system-generated passwords expire after 60 days. If you are a new user who has never logged in, ask your administrator to provide you with a new temporary password.
I received the message, "We recognize your login credentials, but a system error occurred when your administrator was assigning your role s in Availity Portal.
Ask your administrator to reassign your roles. I received an SC01 error. The SC01 is a security-related error message used for truly unexpected exceptions such as lost database connections and errors related to problems at our third-party hosting vendor.
This error message can display when you are trying to log in or are performing account administration functions. If this problem occurs, wait a few minutes and try again. If this problem continues, call Availity Client Services for assistance. Note: Before calling Availity Client Services, please note the timestamp, session number, code, and transaction ID displayed at the bottom of the error message, and then give this information to the Availity Client Services associate.
I can check, make follow-ups, and file for disputes online. There is no need to place a phone call or wait for replies via fax and email.
I'm able to submit claims and get approvals in less than two hours. With this process, our company is assured that insurance companies pay us right on time. This is because of incomplete information from the system. If this happens, I always end up making a few phone calls to fix things. The good thing is that this doesn't happen often. We had to do things manually, which very challenging because we also have to multitask and talk to patients at the same time. Using this software has made a significant impact on our lives.
Based on my personal experience, I no longer have to spend long hours calling insurance companies to verify some information from their reps. CONS: Part of my job is to determine the type of plan each patient has before I could qualify him for a procedure. When doing this through Availity, I need to through several steps as part of their verification process.
I find it challenging because there are times when I only have limited information on the patients' files. Usually, it would ask for the patient's birthday or NPI code, which is not readily available. User-friendly and provides fast results which is very much appreciated. PROS: I can accomplish more tasks and paperwork at the office. No need to spend more than 50 percent of my time waiting or chatting with insurance agents.
I can easily retrieve whatever information I need using Availity. It's easy to learn, and I feel more productive, which is a good thing. CONS: Sometimes the system is down so we couldn't use it for several hours. Also, there are instances wherein the total amount used is not shown on file, so I need to verify that information manually. It addresses the majority of our issues regarding insurance claims and billing. Availity is a one of a kind platform that allows you to handle billing and insurance stuff all the same time.
I can arrange my daily schedule and treat my patients on time. The platform is so useful that it reduces the time that I usually spend on the phone and fill up different forms, which is so time-consuming.
CONS: They cannot cover all insurance companies in the country, so we still have to verify information over the phone from time to time. I wish that they could upgrade their platform so we would always be able to cater to a broader customer base.
There are other options, though, but some clients have their preferences. Since most patients depend on their health insurance, we can quickly screen or determine if they are qualified for a particular procedure or not. An increasing number of patients have been coming in for consults, and that is a clear sign that our business is picking up. CONS: We are sometimes having issues with the accuracy of patient records and insurance coverage. In cases like this, we have no choice but to give the insurance company a call for further clarification.
This process is time-consuming and sometimes frustrating, especially for elderly patients. Although it doesn't happen all the time, it would be best if they could fix this to ensure that all verification processes go on smoothly. PROS: This platform is handy and informative in our line of business. Every day we deal with tons of medical claims coming from our patients. We are thankful for Availity because it provides us the information we need before treating patients, which is very convenient.
CONS: Dealing with rejected claims is such a big headache. No one wants to deal with it because it's too stressful on our end, but we have no choice but to do it. However, we found out that not all insurance companies are allowed to file an online dispute through Availity.
Meaning we need to go through a long process, which sometimes takes days to resolve. PROS: The program is easy to install use. We introduced it to our new hires and were given their access in just a few hours. In case they get locked out, it's also easy to request for a PW reset and get back to work.
CONS: The only problem that we encounter is when the system becomes latent or stops working for a few hours. If this happens, we have to pick up our phones, do a manual verification, and deal with more backlogs.
Intelligent layout plus its a results-oriented platform. Plus I learned to use it in two days. PROS: There is no need to place a call to the insurance companies to verify if a specific claim has been approved or not. Availity offers us the convenience by merely logging in to the system and pulling up the required data. CONS: Limited access to some information. I wish the platform would unlock it in the future because there are things that we would like to know in advance.
Having visibility regarding the schedule of payments from all insurance companies would be very much appreciated. This way, we can project our monthly income and make adjustments to our expenses if necessary.
The results are fast and accurate. It takes good care of more than half of our daily workload. From verifying claims, filing for disputes, following up on invoices and payments, name it, and Availity can do it for you. CONS: Other insurance companies take advantage of the system. Some of them tend to overdo claims investigation, which makes matters more complicated. Availity changed the way we verify insurance coverage because we work fast and efficiently.
PROS: There is no need to ask my secretary to come to work 2 hours before the clinic opens to call the insurance company. Now we can get all the information needed for our customers in a few minutes.
I also noticed that my staff is more motivated to accept patients because their workload is now made more comfortable. CONS: They need to work on missing or incomplete information. This may sound like a minor issue to most clients, but it leaves us feeling disappointed. We paid for the platform, and we expect excellent service in return. Availity makes our process less complicated for everyone in the company. PROS: It's so easy to learn how to use the whole platform. The learning process took us only two days tops.
We are currently using this app to help us determine the patients' insurance coverage. Normally we would spend Hours calling the insurance hotline to get the information that we need.
But with the help of Availity, it takes us a few minutes to complete this particular task. CONS: The layout needs a lot of improvement. I find it dull and unappealing. It would be best if they could do something about it too so people would find more interest in using the platform. We can help people that are suffering from depression and other issues regarding mental health. Thanks to Availity for allowing us to maximize the platform. PROS: I am usually loaded with tons of verification tasks and other workloads in the office, and I'm always behind things.
With Availity, I was able to do more things, such as checking our remittances from insurance companies. CONS: I need to dedicate some time to learn more about the platform.
I'm new to this, so there are times that I feel challenged. But if I familiarize myself with Availity, things will be better. I am usually loaded with tons of verification tasks and other workloads in the office, and I'm always behind things.
The site is full of information. It can make follow-ups on insurance claims by batches. It doesn't take too much time and effort to verify claims. Rather than calling all, I need to do is research.
It saves me a lot of time and reduces the amount of paperwork that I need to work on at the office. I didn't have any difficulties using the site because of its ergonomic layout. CONS: I think that my major complaint is the limited number of insurance companies that the platform supports.
We have clients who have insurance with other companies that Availity is unable to support. Of that's the case, I have no choice but to do all of the work manually, which is cumbersome, especially if I have similar cases within the day. Also, I would like to point out that since the site is loaded with too much data, I sometimes feel overwhelmed.
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