Regulatory amendment to Aetna provider agreements (NY DOH Standard Clauses)
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This amendment incorporates the New York State Department of Health Standard Clauses (revised 04/01/2017) and related appendices into existing Aetna provider agreements, governing contractual terms between Aetna (and affiliates) and Providers/IPA/ACOs who contract with Article 44 plans in New York.
The incorporation provision in the Agreement is deleted and replaced to expressly incorporate the New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts, which will prevail over inconsistent Agreement language except as required by law.
Appendix A 'Standard Clauses' (Revised 5/1/15) is deleted and replaced with Appendix A 'New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts Revised 04/01/2017.'
Appendix B 'Certification Regarding Lobbying' is added as referenced in the Standard Clauses.
Contractual Coverage & Operational Criteria
Contractual coverage- and payment-related criteria
Provider billing and enrollee liability rules under the Agreement include:
Contractual operational criteria
Operational contract requirements and protections
Claims Coding, Administrative Provisions, and Notices
| CPT/HCPCS | Claims must conform to AMA CPT or CMS HCPCS coding, reporting guidelines and conventions. |
| No specific procedure or diagnosis codes referenced in this section of the document. |
Provider Responsibilities and Requirements
Comply with MCO utilization management, precertification, referrals and reporting
Providers must comply fully with MCO utilization management rules, policies and procedures provided at least 30 days before implementation, including quality improvement/management, utilization management (including precertification procedures, referral processes or protocols, and reporting of clinical encounter data), member grievance procedures, and Provider credentialing.
- MCO must provide applicable rules, policies and procedures to Provider at least thirty (30) days in advance of implementation.
- Utilization management obligations include precertification procedures, referral processes/protocols, and reporting of clinical encounter data.
Provide medical records, encounter data and obtain enrollee consent
Upon appropriate enrollee consent/authorization, Providers must make medical records, encounter data and other personally identifiable information available to the MCO (and IPA/ACO if applicable) and to the State for purposes including preauthorization, concurrent review, quality assurance (including QARR), payment processing, program qualification, audits and recovery of overpayments; Providers must provide such records to DOH at no cost and retain records for six years after the date of service (longer for minors).
- Obtain appropriate consent/authorization from the enrollee before disclosure.
- Make records available for preauthorization, concurrent review, quality assurance, payment processing, newborn SSI eligibility, and overpayment analysis/recovery.
- Provide records and required financial data/reports to MCO and State agencies (including DOH, OMIG, HHS and others) on request at no cost to the State.
- Retain medical records for six years after date of service (for minors, three years after majority or six years after date of service, whichever is later).
Key Definitions from the Standard Clauses
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