Download NH 512-01 Non Par Provider Policy

NCM 512-01
National Approval Date: 04/18/11
Effective Date: 07/18/11
National Care
Management
Subject
Originating Department
National Care Management
Non-Participating Provider Policy
Review and Revised Dates:
July 2004, September 2005, June 2006, June 2007, June 2008,
March 2009, March 2010, April 2011
Signed original on file in National Care Management
Date: 4/18/11
Signature Authority: James D. Cross, M.D.
Applies to
Department:
 PM
 Precertification
 NME
 WH
 BH
 DM
 IHL
Product:
 HMO
 EPO
 PPO
 MC/POS
 TC
 Medicare
Advantage
(HMO)
 Medicare
Advantage
(PPO)
Type:
 New
 Revision
 Replacement
 Review –
No changes
Related Materials:
NCM 100-01
NCM 200-01
NCM 200-02
National Care Management Precertification Policy
National Care Management Concurrent Review and Discharge Planning Policy
National Care Management Concurrent Review and Discharge Planning
Procedure
NCM 500-02
Use of Board Certified Specialty Reviewer Procedure
NCM 503-01
National Care Management Medical Review Policy
NCM 504-02
National Care Management Timeliness Standards for Coverage Decisions and
Notification Procedure
NCM 506-01
National Care Management Peer-to-Peer Review Policy
NCM 506-02
National Care Management Peer-to-Peer Review Procedure
NCM 512-02
National Care Management Non-Participating Provider Procedure
NCM 517-02
National Care Management Travel and Lodging Procedure
NCM 902-01
National Care Management Medicare Advantage Out of Area Policy
NCM 902-02
National Care Management Medicare Advantage Out of Area Procedure
NCM 903-02
National Care Management Medicare Advantage U.S. Travel Advantage
Procedure
Behavioral Health Outpatient Ad Hoc Guide Performance Support Tool at:
http://aetnet.aetna.com/cware/proc_nav/pn_abh_outpatient_adhoc/index.html
National Precertification: Non-Participating Provider Workflow at:
http://aetnet.aetna.com/natlprecert/precert/prec_national_workflows_page.htm
Aetna Product Summary at:
http://aetnet.aetna.com/medOps/contentMgtAssets/documents/UMResources/Ae
tnaProductSummary.xls
Resources:
NCM 100-02
NCM 500-01
National Care Management Precertification Procedure
Use of Board Certified Specialty Reviewer Policy
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
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Page 1 of 11
National Care Management
Non-Participating Provider Policy
NCM 512-01
NCM 504-01
National Care Management Timeliness Standards for Coverage Decisions and
Notification Policy
NCM 503-02
National Care Management Medical Review Procedure
NCM 505-01
National Care Management Denial of Coverage Policy
NCM 505-02
National Care Management Denial of Coverage Procedure
NCM 517-01
National Care Management Travel and Lodging Policy
NCM 600-01
National Care Management Transition of Care Coverage Policy
NCM 600-02
National Care Management Transition of Care Coverage Procedure
NCM 903-01
National Care Management Medicare Advantage U.S. Travel Advantage Policy
QM 10
National Quality Management and Measurement Policy: Practitioner and
Provider Availability: Network Composition and Contracting Plan
National Precertification: Alternate Office Call (AOC) Handling & State Utilization Review (UR)
Reference Pages at: http://aetnet.aetna.com/natlprecert/precert_main.htm
Attachments:
None Applicable
Policy Statements:
A. General:
A non-participating provider is defined as a physician, dentist, hospital, skilled nursing facility or other
individual or entity involved in the delivery of health care or an ancillary service that does not have an
agreement to participate in Aetna’s network and provide covered services to Aetna members.

Contractual agreements are product specific (e.g., a provider may be contracted for all or a
specific combination of Aetna products).
o
Providers who are not contracted to participate with all Aetna products are identified as nonparticipating for members enrolled in products that are not included in the provider’s Aetna
contract (e.g., a provider contracted for only Open Choice [OC] members is considered nonparticipating for HMO members).
○
Providers are only contracted for the Medicare Advantage products in the geographic areas
in which the Medicare products are offered.
○
Aetna participating practitioners who are not designated for inclusion within the identified
Aexcel® specialty categories (Non-Designated Specialists) and Aetna participating
practitioners who opt out of Aexcel are considered non-participating for members enrolled in
plans that include a concentric Aexcel network.
 For members enrolled in plans that include a concentric Aexcel network, a request for
coverage 1 of covered services to be rendered by a Non-Designated Specialist or a nonparticipating provider requires precertification in order to be eligible for payment.
1
For these purposes, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit
pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization
management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.
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National Care Management
Non-Participating Provider Policy
o
Aetna participating practitioners who are not designated for inclusion within the identified
Aexcel specialty categories and practitioners who opt out of Aexcel are considered
participating for plans that include a multi-tiered Aexcel Plus network. Members have a
higher cost sharing responsibility when accessing these participating practitioners. The
same cost sharing principles apply to members enrolled in a multi-tiered specific plan/home
host Integrated Delivery System (IDS) network or a plan that includes a Benefit,
Engagement, and Network Strategies (BEN) program 2 . Use of an Aetna participating
provider not included in the IDS network or not designated as a Choose and Save hospital
(as applicable) results in additional member financial responsibility.


NCM 512-01
Requests for coverage of non-participating provider services at an in-network benefit
level requires precertification for members enrolled in a plan that includes a multi-tiered
Aexcel Plus, IDS network or BEN program. If approved, the in-network benefit level is
not equivalent to the Aexcel practitioner/IDS provider/BEN tier 1 program benefit as
there is no provision for coverage of non-participating provider services at the highest
level of benefits for these plans/programs.
Members enrolled in Medicare Advantage plans who electively access a non-participating
provider who has either opted out of Medicare or who has been debarred/sanctioned are
financially responsible for all services. Non-participating providers who have opted out of
Medicare or who have been debarred/sanctioned are eligible for payment consideration for
emergency or urgently needed services.
Members enrolled in plans that do not require a primary care physician (PCP) selection may access
covered services at the in-network level of benefits from any contracted provider when precertification
is not required for the specified procedure/service. Alternatively, members enrolled in plans that require
a PCP selection may access covered services at the in-network level of benefits from any contracted
provider with a valid PCP referral when precertification is not required for the specified
procedure/service. Behavioral health services do not require a PCP referral.

The presence of a referral from a member’s PCP to a practitioner not included in the plan
network does not impact the level of benefits applied to a claim for members enrolled in a plan
that includes a multi-tiered network.

Referrals and in-network benefits, as applicable, are not limited to a specific geographical area
(unless required by state law or regulation) but rather are determined by the contractual terms of
a provider agreement. For example, if a Massachusetts provider is contracted for the HMO
product, then a New Jersey HMO member may access that Massachusetts participating
provider with a PCP referral.
•
2
Two exceptions exist to the applicability of this plan specification for referrals/in-network
benefits:

The Aetna Federal Government HMO plan (Federal Employee Health Benefits Program
[FEHBP]) limits in-network benefits for routine care to a specific geographic service area.

Medicare Advantage HMO members are limited to receiving in-network care within the
defined service area, or a contiguous area, except for emergency care or urgent care.
The member facing name for BEN is Choose and Save.
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National Care Management
Non-Participating Provider Policy
NCM 512-01

The exception to the routine access rule for Medicare Advantage HMO members
who are temporarily out of the service area is that renal dialysis is eligible for
coverage when services are received from a Medicare qualified dialysis provider. In
addition, Medicare Advantage HMO members, while enrolled in the Travel
Advantage Program may access covered services when outside the original
assigned service area following (NCM 903-01) National Care Management Medicare
Advantage U.S. Travel Advantage Policy.
This policy does not apply to requests for members undergoing an active course of treatment at the
time of enrollment/re-enrollment or at the time an Aetna participating provider terminates their Aetna
contract. These transition of care coverage requests are handled following (NCM 600-01 & 02) National
Care Management Transition of Care Coverage Policy and Procedure.
B. Health Plan and Product Applicability:
Aetna maintains a broad network of participating PCPs, specialists and facilities within each defined
service area. Network adequacy is defined by product and by market, and is monitored and confirmed
by Network and Quality Management through Geo Access reports.

Standards for provider availability are set forth following (QM 10) National Quality Management
and Measurement Policy: Practitioner and Provider Availability: Network Composition and
Contracting Plan and are in compliance with accreditation standards and applicable state and
federal laws and regulations.

Sites with Medicare contracts incorporate a standard of thirty (30) minutes drive time modified to
meet patterns of care.

Plans that include Aexcel or IDS networks or a BEN program are subject to the applicable plan
network specifications.
1. HMO, HMO Open Access, Elect Choice, Elect Choice Open Access Plans and Health Network
Only:
These Aetna plans generally do not provide benefits for services rendered by non-participating
providers except for emergency or out of area urgent care.

Requests for coverage of elective non-behavioral health services from a non-participating
provider must be submitted by the PCP or the referring participating provider with the exception
of Open Access plans for which members may initiate non-participating provider coverage
requests.

Elective non-participating behavioral health coverage requests may be submitted by the
member, by the treating provider (participating or non-participating), or by the PCP.

Members who have been seen electively by a non-participating provider without prior approval
are notified that coverage is denied, which may include all services and facility charges.
2. Quality Point of Service (QPOS), Managed Choice (MC), MC Open Access, Health Network
Option and Open Choice (OC):
These Aetna plans include an out-of-network benefit component that provides payment of covered
services rendered by non-participating or “non-preferred” providers.

Generally, out-of-network benefits are subject to higher cost sharing through deductibles and
coinsurance.
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National Care Management
Non-Participating Provider Policy

NCM 512-01
Members or providers may initiate a non-participating provider coverage request for in-network
benefits. Claims from non-participating providers are paid according to the plan benefit
structure when services are provided without prior approval at the in-network level of benefits.
o
Approval at the in-network benefit level for network inadequacy for members enrolled in OC
plans is generally at the “other care” tier of benefits. The preferred in-network benefit level
is limited to coverage approvals due to network inadequacy for OC plans that do not include
an “other care” tier of benefits.
3. Medicare Advantage HMO, Medicare Advantage HMO Open Access, and Medicare Advantage
PPO:

Members and providers (both contracted and non-contracted) may submit a pre-service
coverage request for an expedited or standard organization determination.

Medicare Advantage HMO and HMO Open Access members who electively access a nonparticipating provider without prior approval at the in-network level of benefits are notified that
coverage is denied, which may include all services and facility charges.

Medicare Advantage PPO members may electively access a non-participating provider without
a referral or prior authorization. In these instances, the member is responsible for higher out-ofpocket cost sharing. Claim payment for non-participating provider services at the in-network
level of benefits is subject to precertification.

Non-participating providers who do not accept Medicare assignment may be accessed
electively by Medicare Advantage PPO members and may be approved during the
precertification process for Medicare Advantage HMO and PPO members for coverage at the
in-network level of benefits.
4. Traditional Choice (TC):
The Non-Participating Provider policy does not apply to Traditional Choice plans as these plans do not
include a provider network. Claim payment is based upon covered services, which are subject to a
deductible and coinsurance.
C. Decision Making:
The Aetna Participating Provider Precertification List and the Behavioral Health Precertification List
identify services that require precertification by participating providers.
1. Precertification:

Payment of services rendered by non-participating providers at the in-network level of benefits 3
for plans that include out-of-network benefits (e.g., QPOS, Medicare Advantage PPO, MC Open
Access, MC, OC, and Health Network Option) or under benefit plans that do not include out-ofnetwork benefits (e.g., HMO, EC, Medicare Advantage HMO, Health Network Only) are eligible
for consideration through the precertification process when the coverage request is received
prior to the date of service.

Members enrolled in plans that include a multi-tiered network (e.g., Aexcel, IDS or BEN) have a
level of payment determination applied to submitted claims based upon whether services were
received from a practitioner or a provider included within the multi-tiered network; an Aetna
participating practitioner or provider not included in the network; or a non-participating
practitioner/provider.
3
All references in this policy to in-network level of benefits for members enrolled in OC plans refer to the “other care” tier of benefits unless the
plan does not include this benefit tier. In the absence of an “other care” level of benefits, the “preferred” benefit level is applied to nonparticipating provider coverage requests that are approved due to network inadequacy for members enrolled in OC plans.
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National Care Management
Non-Participating Provider Policy
NCM 512-01
a. Elements of Decision:
Precertification for non-participating provider services at the in-network level of benefits includes Aetna
physician Medical Director/psychiatrist/psychologist 4 review (except as noted below) and a
determination that the requested service cannot be provided within the market defined access
standard.

An exception to the use of the market access standard may be made for requested coverage
with a non-participating provider outside of the market access standard. In this case, the travel
distance and/or appointment availability for the requested non-participating provider is
substituted as the standard against which the availability of the participating provider is based.
For example:
o
If the coverage request is for use of a non-participating provider 75 miles from the member’s
home, and the market access standard is 30 miles, then the availability of a participating
provider 75 miles from the member’s home (rather than the market access standard of 30
miles) is acceptable as part of the non-participating provider coverage request process.
o
If the non-participating provider appointment is scheduled 30 days in the future and the
market access standard for this type of practitioner is 10 business days for a routine
appointment, then the availability of a participating provider appointment within 30 days is
acceptable as part of the non-participating provider coverage request process.

State mandates for minimum and/or maximum requirements supersede the market defined
access standards.

Patient Management/National Precertification/Behavioral Health/National Medical Excellence
and Women’s Health staff 5 document confirmation in eTUMS of the names of the identified
participating providers who are accepting new patients and who can treat the member’s
condition as part of the coverage determination process.
Situations that may be authorized without Aetna physician Medical Director/psychiatrist/psychologist
review include, but are not limited to:

Follow-up to initial Emergency Room (ER) treatment by an ER physician or specialist as
indicated by ER discharge instructions (e.g., evaluation of a non-displaced fracture by a nonparticipating orthopedist 2 weeks post ER casting);

Follow-up to emergency surgery performed within the previous 90 days;

Legislatively mandated coverage;

Known network gaps documented by on-line systems (e.g., Doc Find, Aetna Strategic Desktop
[ASD]) or another resource such as the state specific Precertification AOC & State UR
Reference Pages Known Network Deficiency Tip Sheet that leads to a definitive conclusion that
a participating provider who can evaluate and treat the member’s condition is not available;

Behavioral health coverage requests that the Care Manager Supervisor determines to be
medically necessary, unique or highly specialized.
4
A licensed psychologist reviews coverage requests that are within the psychologist’s scope of practice and for which the psychologist’s
clinical experience provides sufficient experience to review the request. A licensed psychologist does not review coverage requests for
inpatient care and/or prescription medications unless state regulations permit.
5
Staff is defined throughout this policy as Aetna Patient Management, National Precertification, Behavioral Health, National Medical
Excellence and Women’s Health employees.
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National Care Management
Non-Participating Provider Policy
NCM 512-01
Elements considered during the review process for requests for in-network benefits for services
rendered by non-participating providers include, but are not limited to:

The information submitted through the precertification process with the supporting rationale for
the request;
o

A review of plan documents to determine whether the requested service is a covered benefit;
o

Requests for additional information required for decision making are handled following the
processes and time frames identified in (NCM 100-02) National Care Management
Precertification Procedure and (NCM 504-01) National Care Management Timeliness
Standards for Coverage Decisions and Notification Policy.
Requests for specifically excluded benefits or limited benefits that have been exhausted are
handled as administrative denials following the (NCM 505-01 & 02) National Care
Management Denial of Coverage Policy and Procedure.
A determination as to whether the service is medically necessary based upon Aetna approved
criteria/guidelines and is unique or highly specialized and is not otherwise available from a
participating provider or the available participating provider falls outside of designated market
access standards.
o
This determination is the responsibility of the Care Manager Supervisor for behavioral health
coverage requests unless the coverage request is not able to be approved. The Care
Manager Supervisor initiates an Aetna physician Medical Director/psychiatrist or
psychologist referral for coverage determination purposes if unable to approve the coverage
request.
o
For non-behavioral health coverage requests, this determination is made (as appropriate) by
an Aetna physician Medical Director.
o
For all coverage requests, outreach is conducted and/or outreach information is utilized that
has been obtained by other staff about alternative network providers confirming that the
alternative provider can evaluate and treat the member’s condition.

o
Outreach may include but is not limited to:

A direct conversation with the PCP or referring provider to include an explanation
that coverage would be available for a second opinion with an alternative network
provider;

A direct conversation with the non-participating provider to include an explanation of
the proposed treatment;

Sending clinical information to the alternative network provider for review (absent any
member identifying information);

Having the alternative network provider speak directly to the non-participating
provider;

Any combination of these approaches.
For chronic renal hemodialysis only, Aetna physician Medical Director review of available
information may confirm that although participating providers exist within the network, a
temporary network deficiency exists based upon capacity issues that preclude the member
from temporarily receiving services within the network.
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National Care Management
Non-Participating Provider Policy


NCM 512-01
In these instances, the member is notified of all of the following:

The non-participating provider authorization is valid for sixty (60) days;

The name of the participating facility where the member will access hemodialysis
services when available; and,

The fact that another non-par referral is required for services beyond the date initially
authorized.
In these instances, Network Management is notified of the identified access issue for
consideration of additional network contracting opportunities. In addition, when
applicable, the Single Case Contracting Unit (SCCU) or Network Management is notified
for potential fee negotiations. 6 (Refer to
http://aetnet.aetna.com/nps/_network_cont_strat/sccu_menu.htm.)
Once the determination has been made that the requested service is not specifically excluded or in the
case of a limited benefit, that the benefit is not exhausted, the non-participating provider coverage
request is referred to the Aetna physician Medical Director or Behavioral Health (BH) Care Manager
Supervisor to determine whether the requested service should be considered as a covered benefit at
the in-network benefit level.

The BH Care Manager Supervisor initiates a referral to an Aetna physician Medical
Director/psychiatrist/psychologist if there is a participating provider available and the BH Care
Manager Supervisor is unable to approve the coverage request.
The Aetna physician Medical Director/psychiatrist/psychologist uses the clinical review process to
determine whether the available participating providers have the appropriate clinical expertise to treat
the member’s condition or to provide the requested procedure/service.

Aetna participating specialty providers are identified based upon the specialty category for
which a board certification exists as described in (NCM 500-01) National Care Management
Use of Board Certified Specialty Reviewer Policy.

An in-network benefit determination for non-participating provider services is considered to be a
clinical determination when treatment is available for the member’s condition from a
participating provider (whether or not a specific procedure/service was requested).
o
For example, a non-participating provider coverage request (at an in-network benefit level)
is specifically for a cholecystectomy by laser technique. It is determined that this procedure
is a covered benefit, yet there is not a participating provider that performs this procedure.
As part of the review process, it is determined that cholecystectomy by laser is not superior
or is generally equivalent to cholecystectomy by other means. The coverage request for innetwork benefits is denied as there are participating providers available to treat this
member's condition (gallbladder disease requiring cholecystectomy).

If an out-of-network benefit level is available under the member's plan, then the specific
procedure/service would be covered at that benefit level.
Note: Had it been determined upon clinical review that the specific requested
procedure/service (e.g., cholecystectomy by laser) was superior and medically necessary,
then an in-network benefit coverage approval determination would be made due to network
inadequacy.
6
SCCU and Network referrals are not initiated for Medicare Advantage members.
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National Care Management
Non-Participating Provider Policy
o
NCM 512-01
If the non-participating provider coverage request (at an in-network benefit level) is for the
treatment of gallbladder disease or cholecystectomy (by any technique), the coverage
request is denied as there are participating providers available to treat this member's
condition (gallbladder disease requiring cholecystectomy).
b. Additional Considerations:
The member’s stability for travel, a determination whether a participating provider is available within the
market access standard or in geographic proximity to the member’s service area, and any applicable
state or federal requirements are considered as part of the coverage determination process when
reviewing a request for in-network benefits for non-emergency services by a non-participating provider.

Members may be eligible for consideration of travel and lodging reimbursement when
participating provider services are authorized outside of the service area and the member meets
the conditions outlined in (NCM 517-01) National Care Management Travel and Lodging
Policy. 7
Reviews for in-network benefits for non-emergency services by non-participating providers also include
consideration of the following factors in addition to provider availability, travel distance and regulatory
requirements:

Continuity of care;

Coordination of follow-up services by participating providers;

Transfer to participating providers within the service area as soon as clinically feasible.
2. Inpatient Review:
The standard level of inpatient review for members hospitalized within non-participating facilities is
concurrent review with discharge planning. The only exception to this review standard is for members
enrolled in Medicare Advantage plans who are followed for discharge planning only. When applicable,
inpatient care that does not meet coverage criteria is referred to an Aetna physician Medical
Director/psychiatrist/psychologist for review.

When the member’s condition is stable, if appropriate, there is coordination by the PCP (as
applicable based upon the plan type when the member is receiving inpatient medical services;
PCP involvement is not required for behavioral health services), the Care Management Team,
and the attending physician to facilitate transfer to a participating facility.

The Care Management Team facilitates the transfer, as appropriate, with the attending
physician and receiving provider for members enrolled in plans in which a PCP is required but
one has not yet been selected, for behavioral health services, and when the PCP is unwilling to
assist with the transfer.
o
For HMO, Medicare Advantage HMO, Health Network Only and EC members, benefits for
services rendered by non-participating providers are available only for the emergency and
stabilization phase of treatment.

Additionally, for Medicare Advantage members, in-network benefits for services
rendered by a non-participating provider may be available for post-stabilization services
following emergency treatment in the following circumstances:

7
If the services requested are authorized by a health plan representative; or,
The travel and lodging allowance is not available for behavioral health services.
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National Care Management
Non-Participating Provider Policy

NCM 512-01
If the health plan fails to respond within one (1) hour from receipt of the coverage
request, the services are payable until alternative arrangements are made for
discharge or transfer.
D. Notification of Determination:
Notification of the non-participating provider coverage determination includes all elements of the
request: both choice of provider and eligibility of the requested service. Clinical guidelines/criteria are
applied to non-participating provider coverage requests following (NCM 503-02) National Care
Management Medical Review Procedure when the coverage request includes clinical information.

Adverse coverage determinations are communicated in writing following established processes
and may include faxed notification for concurrent review decisions to the member or member
authorized representative 8 as noted in (NCM 505-01) National Care Management Denial of
Coverage Policy.
o

Written notification of adverse determinations for elective non-participating provider innetwork benefit coverage requests includes:

Notice that claim payment will be denied for plans without out-of-network benefits or that
payment will be processed at the out-of-network benefit level for plans that include outof-network benefits; and,

The names and phone numbers of the alternative participating providers who have
confirmed that they are able to evaluate and treat the member’s condition.
Coverage approval for services rendered by a non-participating provider is communicated
verbally and, when mandated or requested, in writing. Written coverage approval determination
letters include:
o
The identification of the services for which coverage is authorized;
o
The time period for the authorization; and,
o
The requirement to utilize participating providers for any additional services not covered
under the authorization or the coverage for those services will be denied.
When non-participating provider services are authorized, a referral to SCCU for potential fee
negotiation is initiated as applicable 9 following the guidelines at:
http://aetnet.aetna.com/nps/_network_cont_strat/sccu_menu.htm.

Providers that participate in the National Advantage Program (NAP) are non-participating and
with the exception of dialysis centers that participate in NAP, are not referred to SCCU for fee
negotiation.
8
For precertification, concurrent and retrospective reviews, an individual must satisfy at least one of the following requirements in order to be
considered an Authorized Representative of a member:

The member has given express written or verbal consent for the individual to represent the member's interests. A member can appoint
an attorney to represent them.

The individual is authorized by law to provide substituted consent for a member (e.g.-parent of a minor, legal guardian, foster parent,
power of attorney); or

For pre-service, urgent care or concurrent claims only, the individual is an immediate family member of the member (e.g.- spouse, parent,
child, sibling); or

For pre-service, urgent care or concurrent care claims only, the individual is a primary caregiver of the member; or

For pre-service, urgent care or urgent concurrent care claims only, the individual is a health care professional with knowledge of the
member's medical condition (e.g. - the treating physician).
9
SCCU and Network referrals are not initiated for Medicare Advantage members.
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National Care Management
Non-Participating Provider Policy

NCM 512-01
Non-participating behavioral health outpatient practitioner services (e.g., office visits) approved
at the preferred benefit level are asked to sign a Letter of Agreement with specific services and
fees which have been agreed to for reimbursement.
o
Periodic reports of non-participating behavioral health practitioners who enter into single
case agreements are provided to Behavioral Health Network staff for outreach and potential
contracting opportunities.
More stringent state requirements may supersede these requirements.
Adoption:
National Quality Oversight Committee Review/Adoption Date: 06/28/2011
Leonard J Harvey, MD
National Quality Oversight Committee Chairperson
Aetna Behavioral Health Quality Oversight Committee Review/Adoption Date: 06/27/2011
Avivah S. Goldman, MSN, MA
Aetna Behavioral Health Quality Oversight Committee Chairperson
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
For Aetna Use Only
Page 11 of 11
NCM 512-01
National Approval Date: 04/18/11
Effective Date: 07/18/11
National Care
Management
Adoption:
Leonard J Harvey, MD
Licensed California Medical Director
Signature
06/28/2011
Date
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
NCM 512-01
National Approval Date: 04/18/11
Effective Date: 07/18/11
National Care
Management
Adoption:
Grant Tarbox, DO
Licensed Oklahoma Medical Director
Signature
06/28/2011
Date
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
NCM 512-01
National Approval Date: 04/18/11
Effective Date: 07/18/11
National Care
Management
Adoption:
Grant Tarbox, DO
Licensed Texas Medical Director
Signature
06/28/2011
Date
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
NCM 512-01
National Approval Date: 04/18/11
Effective Date: 07/18/11
National Care
Management
Adoption:
Haydee Muse, MD
Licensed Missouri Medical Director
Signature
06/13/2011
Date
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
NCM 512-01
National Approval Date: 04/18/11
Effective Date: 07/18/11
National Care
Management
Adoption:
Lionel E Tapia, MD
Licensed Montana Medical Director
06/14/2011
Date
Signature
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna)
April 2011
For Aetna Use Only