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
- Mental Health Resources and Support - Information and support for mental health.
- Crisis and Disaster - Resources to address tragedy and times of uncertainty.
- Depression in Primary Care program - Depression resources for your patients and you.
Telehealth
- Telehealth Services - Learn about Aetna’s virtual care services and member benefits.
- Teladoc - The Aetna health plans give access to virtual care through Teladoc.
Prior Authorization
- Prior Authorization Requests - Requestions authorizations for selected procedures and submit requested clinical information.
- Precertification Lists - Precertification information and lists for procedures and services.
- National Precertification List (NPL) - Changes to Aetna’s NPL effective 9/1/2022 to commercial and Medicare plans.
- Submit precertification requests though the Availity provider portal.
Value-Based Programs/Alternative Payment Models
- Healthy happens together: 2021 Value-Based Programs - Michigan
- Aetna Value-Based Continuum - Delaware
Medicare Advantage
- Medicare Resources for Providers - Information about Medicare compliance requirements, training, enrollment, appeals and more.
Recent News
- Aetna Newsletter - Past and present Aetna newsletters and important reminders.
Elevance Health (formerly known as Anthem)
Behavioral and Mental Health
- Behavioral Health Provider Resources - Search for your state for behavioral health related information.
- Behavioral Health Outpatient Treatment Authorization - Prior authorization form for behavioral health treatment.
Telehealth
- Anthem Telehealth - Learn about Anthem’s virtual care services and how to use the Anthem Sydney app.
Prior Authorization
- Prior Authorization - Search for your state for prior authorization specific information such as code lists, precertification lists, polices, and guidelines.
- Inpatient/Outpatient Prior Authorization Request - Prior authorization request form or inpatient or outpatient visits.
- Medicare Advantage General Precertification Request - General precertification request form.
Value-Based Programs/Alternative Payment Models
- Reimbursement Policies - Search for your state to review Anthem’s reimbursement policies and the basis for reimbursement if the service is covered by Anthem.
- Electronic Data Interchange - Anthem has a strategic relationship with Availity to serve their Electronic Data Interchange (EDI). Register here to exchange claims electronic transactions with Anthem.
- Enhanced Personal Care - Search for your state to learn more about Anthem’s value-based care program.
Medicare Advantage
- Medicare Advantage Plans - Information on understanding the MA program, virtual care, and using MA encounter data.
- Medicare Advantage Providers - Information for providers with access to information about our plans and member benefits, news and updates, training materials and guides.
Recent News/Other
- Provider News - Search for your state and stay current on Anthem policies and processes, updated clinical guidelines and other issues impacting your practice and patients.
- Forms & Guides - Search for your state and use these tools needed to deliver quality care and support patients and staff.
Blue Cross Blue Shield
- Behavioral Health - Learn about the new behavioral health network effective January 1, 2023.
- FAQs - Provider information on vaccine and boosters, testing, treatment, telemedicine, and more.
- Medicare Advantage - Information on MA costs, limits and considerations, and enrollment.
- Provider Hub - Updates on care and coverage related to COVID-19.
Cigna
Behavioral and Mental Health
- Mind-Body Connection - 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.
- Behavioral Health Resources - Includes clinical practice tools, behavioral administrative guidelines, and more treatment guidelines.
Telehealth
- Cigna’s Virtual Care (Telehealth) Services - Learn about Cigna’s virtual care options including preventive, urgent, and behavioral/mental health care.
- Virtual Care - Read Cigna’s virtual care reimbursement policy to ensure you can continue receiving ongoing reimbursement for virtual care.
Prior Authorization
- Precertification Guidelines - 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.
- Clinical Reimbursement Policies and Payment Policies - Find the most recent Medical Necessity Review list, precertification policies, and modifiers and reimbursement policies.
- Master Precertification List - Complete list of services that require precertification of coverage.
Value-Based Programs/Alternative Payment Models
- Cigna Collaborative Care for Specialists - Collaboration between Cigna and a physician practice that's responsible and accountable for the population it serves.
Medicare Advantage
- Medicare Advantage Providers - Providers manuals and resources for treating MA patients.
Recent News
- Policy Updates - Past and present Cigna policy updates.
Humana
Behavioral and Mental Health
- Behavioral Health Guidelines - Evidence-based treatment options for common behavioral health conditions.
- Depression Screening Resources for Primary Care Providers - Tools and resources to screen for depression.
Telehealth
- Telehealth and virtual care resources - Technology requirements, eligibility and patient consent, patient marketing resources, comprehensive telehealth playbook, and FAQs.
- Telehealth FAQs - Visit this page for all your telehealth billing questions and answers.
Prior Authorization
- Preauthorization and notification lists - 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
- Value-based care report - Details prevention, outcomes and utilization, and costs and payments for Humana individual Medicare Advantage (MA) members in 2021.
- Episode-based Models - 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
- Medicare Advantage Materials - 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
- United Behavioral Health Prevention Center - Use the access code ‘united’, then click on Mind & Body > Mental Health and/or Substance Use Disorder/Addiction.
- Behavioral Health Resources - Reference guide of resources to help screen patients for depression, Attention Deficit Hyperactivity Disorder (ADHD) and alcohol/substance misuse.
Telehealth
- Virtual Visits Guide - Information for members on benefits and coverage for telehealth services.
- Telehealth/Virtual Health Policy - This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form or its electronic equivalent or its successor form.
Prior Authorization
- Prior Authorization and Notification Portal - Submit, complete, and track prior authorizations and determine the need for notification. [requires login]
- What UHC is Doing to Ease Prior Authorizations - 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
- Oncology Value-Based Programs - Information on Cancer Therapy Pathways and Cancer Episode programs.
Medicare Advantage
- 2023 UnitedHealthcare Care Provider Administrative Guide for Commercial and Medicare Advantage - This guide provides information on topics such as claims and prior authorization.
- UnitedHealthcare Medicare Advantage Policies, Coverage Summaries and Guidelines - 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
- AHIP- 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.)
- Payer Contracting
This slideshow details what should be included in any contract between a physician and payer. - Managed Care Legal Database – 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.
- Optum Pay Payment Program
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