Long-term care (LTC)

For general information on becoming a contracted physician, please visit our “Join our network” page. Providers can start the contracting process by submitting an inquiry through our provider intake form.

If you need further assistance with the contracting process, after submitting a request via the provider intake form, you may also email us  or call us at 1-866-329-4701 (TTY: 711). Ask to be directed to the Contracting department. The Provider Relations team will reach out to LTC facilities within 30 days of their effective date to set up orientations and answer any questions they have about their contract.

The rounding physicians in the LTC facility can continue to provide the same care they did in the past, even without a contract. While the member may receive an ID card with a new primary care physician’s (PCP’s) name — the rounding physicians can continue to provide care without disruption. When billing, physicians should bill Aetna Better Health of Illinois for the services they are providing to the resident.
 

We have been in close contact with many LTC facilities to explain this process to administrators. If there are further questions, or if a facility would like to set up a meeting with Aetna Better Health, please contact us at 1-866-329-4701 (TTY: 711).

Both emergent behavioral health and nonbehavioral health hospitalizations are covered at participating and nonparticipating facilities. We are making great progress with our hospital network. If an LTC facility resident is hospitalized at a nonparticipating facility for nonurgent or emergent care, the Aetna Better Health Integrated Care Coordination team can help by:
 

• Assisting the facility to identify participating providers and facilities

• Coordinating a Single-Case Agreement, when the medically necessary care is not available at a participating facility

• Helping the facility coordinate transportation and follow-up care needs and developing a comprehensive medical and psychosocial care plan based on the member’s care needs and any gaps identified during discharge planning or through a Health Risk Assessment

You can reach the Aetna Better Health Integrated Care team at 1-866-329-4701 (TTY: 711).

Aetna Better Health already has contracts in place with various facilities in the 606 ZIP code area. If a facility is not contracted with us, they need to can contact us for an authorization for the admission. These can be faxed to Prior Authorization. The facility needs to bill the member’s health plan. All claims for Aetna Better Health members can be sent here:

Physical Health Prior Authorization: faxed to 1-877-779-5234

Behavioral Health Prior Authorization: faxed to 1-844-528-3453

Paper Claims: mailed to

Aetna Better Health of Illinois

P.O. Box 982970

El Paso, TX 79998-2970

Yes. You must submit a claim to Aetna Better Health using a CMS 1450 (UB-04) form.

Any room and board revenue code can be used.  A useful resource for finding appropriate revenue codes can be found in the link below.

Find-a-Code listing of UB04/CMS1450 Revenue Codes — Group 01

There are varying circumstances surrounding coverage by us. Please contact our office at 1-866-329-4701 (TTY: 711) for specifics regarding a particular member.

We are responsible for the first 90 days of a new benefits period.

We will pay the per diem rate, as supplied by the International Professional Development Association (IPDA).

Medically necessary DME is covered when it is provided by a state-certified DME provider.

Yes. You are still required to submit a “Welcome Packet” to IPDA for each new admission. Once that process is complete, the state of Illinois will let us know by including the member in the Patient Credit File. 

Note: 

If this process is not completed, Aetna Better Health will not pay for any claims.

The first six visits for medically necessary therapy provided by an entity other than the LTC facility are covered without the need for authorization. All visits thereafter require authorization to establish if each one is medically necessary or not.

Inpatient hospice is handled as pass-through billing by the hospice provider. Aetna Better Health will pay 95% of the LTC facility’s per diem rate, and the hospice agency is responsible for paying the facility. This arrangement must be agreed upon between the hospice agency and the LTC facility. Aetna Better Health is not part of this negotiation. Please refer to the Illinois Handbook for Hospice Agencies (PDF).

Bed-holds for adults 21 and older are not covered. In accordance with the State and Municipal Assistance for Recovery and Transition (SMART) Act, which went into effect on April 1, 2013, Aetna Better Health implemented the HFS change that eliminated bed-holds for adults who are 21 and older in nursing homes.