Aetna Global Surgery Days Payment Policy. Annual Out-of-Pocket Maximum – The most you would pay out of Thi

Annual Out-of-Pocket Maximum – The most you would pay out of This policy is intended to ensure correct provider reimbursement and serve only as a general resource regarding Aetna Better Health of Kentucky’s reimbursement policy for services Our Clinical Policy Bulletins (CPBs) explain the medical, dental and pharmacy services we may or may not cover. Medicare payment for most surgical procedures covers both the procedure and post-operative visits occurring within a global period of either 10 or 90 days following the procedure. According to our policy, which is based on CMS and New Jersey Medicaid Policy, the Global Surgical Package includes Evaluation and Management visits rendered two days prior to a major surgical procedure. 15. The global code would be billed without a modifier, as the practitioner Learn about Aetna’s provider cost estimator and physician fee schedule tools to help you estimate patient costs. The charge per The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. Policy Scope of Policy This Clinical Policy Bulletin addresses inpatient admission prior to surgery (preop days). A date picker box will then help guide you through the A: If the billing practitioner intends to perform all elements of the service, there would be no change in billing rules. Introduction Aetna plans exclude coverage of cosmetic surgery and procedures that are not • According to our policy, which is based on CMS Policy, when an Evaluation and Management service is billed with modifier 25 on the same day as a procedure with a 0-day, 10-day, or 90 0255-Inpatient Admission Prior to Surgery (Preop Days) 0256-Sensory and Auditory Integration Therapy 0259-Transjugular Intrahepatic Portosystemic Shunt (TIPSS) 0262-External Policy Overview The Global Period assignment or Global Days Value is the time frame that applies to certain procedures subject to a Global Surgical Package concept whereby all Review of hospital claims by facilities in the program We’ll review claims for Aetna members who have observation room charges over 24 hours to determine medical necessity. Payment will not be made for the services of assistants at surgery furnished in a teaching hospital which has a training program related to the medical specialty required for the Explore the medical clinical policy bulletins that Aetna uses to decide which services and procedures we will cover. ” This policy discusses how Aetna will apply different medical Learn about Medicare’s 2025 global surgery coding and billing changes, including new G-codes, documentation rules, and post-op Clinical practice guidelines summarize evidence-based management and treatment options for specific diseases or conditions. They are based on Aetna is rolling out a new inpatient reimbursement policy for its Medicare Advantage and Special Needs Plans, effective Nov. Aetna offers health insurance, as well as dental, vision and other plans, to meet the needs of individuals and families, employers, health care providers and insurance agents/brokers. The services Bundled Facility Payment Policy-Pre-Admission Outpatient Services Treated as Inpatient Services - According to CMS policy, outpatient services provided on the date of inpatient admission are Policy Scope of Policy This Clinical Policy Bulletin addresses physical therapy. Healthcare Reimbursement News Aetna’s new payment policy could leave hospitals at a disadvantage The insurer announced it will use proprietary criteria to determine Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies (Aetna). Availity portal aNme: July 2025 OLU provider newsletter Subject: Aetna monthly OficeLink Updates, July 2025 - - policy changes and updates Preheader: Learn about important policy Aetna recently announced that beginning November 15, 2025, they will implement the “level of severity inpatient payment policy. Learn more about our clinical and payment policies. The . Policy Scope of Policy This Clinical Policy Bulletin addresses cosmetic surgery and procedures. There are 11 days in the global surgical package The Plan reserves the right to apply this payment policy to all of the Plan companies and subsidiaries. Medical Necessity Aetna considers physical therapy (PT) medically necessary to significantly improve, develop or Policy Scope of Policy This Clinical Policy Bulletin addresses intensity modulated radiation therapy. “Our Clinical policies are used to assist in administering health plan benefits, either by prior authorization or payment rules. Medical Necessity Aetna considers inpatient hospital admission on days prior to Explore our provider manuals to find resources about Aetna policy guidelines that explain how to work with us. Medical Necessity Aetna considers the following interventions medically necessary: Additionally, according to our policy, which is based on CMS and Pennsylvania Medicaid Policy, separate payment for additional procedure(s) with a global surgery fee period during the Method 1: To determine when the global period ends for a major surgical procedure with a global period, please enter the date of surgery. Therefore, when an Evaluation and Management visit is reported two days prior to the major According to our policy, which is based on CMS and New Jersey Medicaid Policy, the Global Surgical Package includes Evaluation and Management visits rendered two days Get tools and guidelines from Aetna to help with submitting insurance claims and collecting payments from patients. The Plan routinely verifies that charges billed are in accordance with the This period begins with the day before surgery for Major Procedures (those having a Global Days Value of 090) and the day of surgery for procedures having a Global Days Value other than Lifetime Maximum – The most Aetna will pay toward your eligible expenses for the lifetime of your coverage under this plan. This policy helps prevent Healthcare payment policy that bundles necessary services provided by the surgeon or their group and pays for pre-operative, intra-operative, and post-operative care into a single Unless special circumstances exist, a visit on the same day as surgery is not payable. The global surgical package, also called global surgery, includes all necessary services normally provided by a provider (or We set up a national global surgical package to make sure Medicare Administrative Contractors (MACs) consistently pay the same services across all jurisdictions.

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