Private insurance companies and their differing policies, procedures, and payments add complexity to medical practice today. These resources are intended to assist practices in dealing with private payers.
Aetna
Mental Health
- - Information and support for mental health.
- - Resources to address tragedy and times of uncertainty.
- - Depression resources for your patients and you.
Telehealth
- - Learn about Aetna’s virtual care services and member benefits.
- - The Aetna health plans give access to virtual care through Teladoc.
Prior Authorization
- - Requestions authorizations for selected procedures and submit requested clinical information.
- - Precertification information and lists for procedures and services.
- - Changes to Aetna’s NPL effective 9/1/2022 to commercial and Medicare plans.
- Submit precertification requests though the .
Value-Based Programs/Alternative Payment Models
- - Michigan
- - Delaware
Medicare Advantage
- - Information about Medicare compliance requirements, training, enrollment, appeals and more.
Recent News
- - Past and present Aetna newsletters and important reminders.
Elevance Health (formerly known as Anthem)
Behavioral and Mental Health
- - Search for your state for behavioral health related information.
- - Prior authorization form for behavioral health treatment.
Telehealth
- - Learn about Anthem’s virtual care services and how to use the Anthem Sydney app.
Prior Authorization
- - Search for your state for prior authorization specific information such as code lists, precertification lists, polices, and guidelines.
- - Prior authorization request form or inpatient or outpatient visits.
- - General precertification request form.
Value-Based Programs/Alternative Payment Models
- - Search for your state to review Anthem’s reimbursement policies and the basis for reimbursement if the service is covered by Anthem.
- - Anthem has a strategic relationship with Availity to serve their Electronic Data Interchange (EDI). Register here to exchange claims electronic transactions with Anthem.
- - Search for your state to learn more about Anthem’s value-based care program.
Medicare Advantage
- - Information on understanding the MA program, virtual care, and using MA encounter data.
- - Information for providers with access to information about our plans and member benefits, news and updates, training materials and guides.
Recent News/Other
- - Search for your state and stay current on Anthem policies and processes, updated clinical guidelines and other issues impacting your practice and patients.
- - Search for your state and use these tools needed to deliver quality care and support patients and staff.
Blue Cross Blue Shield
- - Learn about the new behavioral health network effective January 1, 2023.
- - Provider information on vaccine and boosters, testing, treatment, telemedicine, and more.
- - Information on MA costs, limits and considerations, and enrollment.
- - Updates on care and coverage related to COVID-19.
Cigna
Behavioral and Mental Health
- - Information and tools to help you and your patients stay emotionally resilient and foster well-being. Includes behavioral health resources for patients, reimbursement for preventive care services and screenings, screening tools, and more.
- - Includes clinical practice tools, behavioral administrative guidelines, and more treatment guidelines.
Telehealth
- - Learn about Cigna’s virtual care options including preventive, urgent, and behavioral/mental health care.
- - Read Cigna’s virtual care reimbursement policy to ensure you can continue receiving ongoing reimbursement for virtual care.
Prior Authorization
- - Guidelines on when and where to submit precertification requests to Cigna and Cigna’s national ancillary vendors. This includes service specific precertification process guidelines- medical procedure, medications, and behavioral.
- - Find the most recent Medical Necessity Review list, precertification policies, and modifiers and reimbursement policies.
- - Complete list of services that require precertification of coverage.
Value-Based Programs/Alternative Payment Models
- - Collaboration between Cigna and a physician practice that's responsible and accountable for the population it serves.
Medicare Advantage
- - Providers manuals and resources for treating MA patients.
Recent News
- - Past and present Cigna policy updates.
Humana
Behavioral and Mental Health
- - Evidence-based treatment options for common behavioral health conditions.
- - Tools and resources to screen for depression.
Telehealth
- - Technology requirements, eligibility and patient consent, patient marketing resources, comprehensive telehealth playbook, and FAQs.
- - Visit this page for all your telehealth billing questions and answers.
Prior Authorization
- - Includes prior, current, and future lists of services and medications for which preauthorization may be required and summaries of changes. Also includes information on submitting requests and state-specific forms.
Value-Based Programs/Alternative Payment Models
- - Details prevention, outcomes and utilization, and costs and payments for Humana individual Medicare Advantage (MA) members in 2021.
- - For episodes of care related to total joint replacement (hip and/or knee), maternity, spinal fusion (lumbar and/or cervical) and coronary artery bypass grafting.
Medicare Advantage
- - Information about the types of MA plans Humana offers. Here you will find reimbursement guidelines, details about provider qualifications and requirements, FAQs, and other information.
United Health
Behavioral and Mental Health
- - Use the access code ‘united’, then click on Mind & Body > Mental Health and/or Substance Use Disorder/Addiction.
- - Reference guide of resources to help screen patients for depression, Attention Deficit Hyperactivity Disorder (ADHD) and alcohol/substance misuse.
Telehealth
- - Information for members on benefits and coverage for telehealth services.
- - This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form or its electronic equivalent or its successor form.
Prior Authorization
- - Submit, complete, and track prior authorizations and determine the need for notification. [requires login]
- - ACP met with UHC as part of their comprehensive effort to simplify the health care experience for consumers and providers. (3/29/2023)
Value-Based Programs/Alternative Payment Models
- - Information on Cancer Therapy Pathways and Cancer Episode programs.
Medicare Advantage
- - This guide provides information on topics such as claims and prior authorization.
- - Coverage summaries, policy guidelines, and reimbursement policies for MA plans. Also included are clinical guidelines and terms and conditions for certain incentive programs.
*Please note that these policies may differ based on your contract with each payer. In addition, some coverage plans may vary for large, self-insured employers.
Additional Private Payer Information
- - Learn about health care coverage, services, and solutions offered by private payers.
- Evaluating Payment Contracts - AMA and RAND created two resources to help physician practices when evaluating bundled or episode-based and pay-for-performance agreements. (Note: Accessing these resources may require registration on the AMA site.)
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This slideshow details what should be included in any contract between a physician and payer.- – This comprehensive resource from the AMA identifies state and federal statutes and regulations that address common issues between private payers and physicians, including payment, coverage, contracts, network, and claims processing issues. The database is searchable by state and by topic.
United Healthcare now offers free downloadable payment information through Optum Pay ACH enrollment.- Template for Physician Letter for Pre-Existing Condition Insurance Plan (PCIP) ACP Member Exclusive