Cofinity Orange Box Aetna Workers' Comp Provider  
Monday, October 20, 2014 




 

About AWCA: Frequently Asked Questions





General Provider Questions

What is the AWCA Product?

AWCA is an Aetna product that provides insurance carriers, third-party administrators and self-insured employers with access to Aetna's workers' compensation provider network. This network consists of physicians, hospitals, pharmacies and other health professionals who provide care to workers who have suffered work-related injuries or illnesses.

What can you expect from this network?

  • Access to additional revenue and new lines of business from Aetna
  • Predictability in medical payments
  • Exposure to Aetna's national customer base
  • Strategic relationship with a well-established brand-name organization
  • Provider service model that parallels our parent infrastructure
  • Financial strength and stability in network partners
  • Educational tools and resources designed specifically to help your office staff increase their knowledge and experience of general and state workers' compensation via links provided within this website

Is Aetna providing workers' compensation insurance through AWCA?

No. Workers' compensation carriers and other customers will work with Aetna to allow workers' compensation claimants access to health-care services through the AWCA network.

How do claimants get access to the AWCA network?

Claimants will get access through their employers, who have contracts with workers' compensation carriers that have a relationship with AWCA.

Whom should I contact if I have more questions about AWCA?

  • To ask network/contract-related questions or questions about the AWCA product and carriers, please contact the AWCA dedicated service unit at 1-800-AETNA-88 (1-800-238-6288). Customer-service representatives are available between 8 a.m. and 5 p.m., ET.
  • For credentialing status, contact Credentialing Customer Service at 1-800-353-1232.

Do all providers that participate with AWCA also participate with Aetna Health Plans?

No. While most providers who participate with Aetna for our health plans also participate in the AWCA network, we do supplement the AWCA network with any interested provider whose specialty may treat a work-related injury and who meets Aetna credentialing standards.

How does AWCA's role differ from the role Aetna typically plays in a medical health benefits situation?

If you participate in Aetna's broader medical network, you are accustomed to Aetna's playing a role in the claims review and payment processes. We do so either as an insurer or a third-party administrator. Workers' compensation is different, and our role is very different. We simply provide our customers with access to the Aetna network of workers' compensation providers who can give care to injured workers.

Reimbursement

How can I see my state-specific fee schedule?

To identify your state-specific maximum fee schedule, you can use the link provided within this website to navigate to your state department that regulates workers' compensation or you can directly contact your state workers' compensation insurance department or commissioner.

Who adjudicates the claim?

AWCA is not the payor and does not adjudicate the claim. The workers' compensation carrier or the third-party administrator will be responsible for adjudicating the bills submitted and may also be responsible for paying for the services (payor). A listing of Aetna customers who access this network is included in this site. The payor is responsible for paying compensable work-related claims.

How does a payor handle my claims?

Payors process claims in accordance with the applicable workers' compensation plan. Payors use their individual processes a) to determine whether billed services are approved for payment pursuant to the payor's clinical and claims edits and b) to determine the Allowable Amount (see below). AWCA does not participate in this bill review and approval process.

What is the Allowable Amount?

The workers' compensation Allowable Amount is the reimbursement amount set by the workers' compensation payor, based either on the applicable state fee schedule (for states that have a fee schedule) or on the payor's "Usual, Customary and Reasonable" amount in other states. It is the amount you would receive for a workers' compensation claim in the absence of any network arrangement such as AWCA.

The Allowable Amount may also include application of a payor's clinical and claims edits (for example, it is the payor, not Aetna, who reviews a claim from a medical necessity perspective and decides whether the bill is payable). Ordinarily, workers' compensation payors do not pay above the Allowable Amount.

What are Compensable Medical Services?

Workers' compensation payors or other third parties typically reimburse for Compensable Medical Services provided at the lesser of a contracted rate, an "Allowable Amount" determined by the payor, or billed charges.

"Compensable Medical Services" are those health care services for which a claimant is entitled to receive benefits under the terms of the claimant's workers' compensation plan. Some expenses that are deemed compensable under the workers' compensation plan may not be determined as "eligible" due to clinical or non-work related type services (e.g. a flu shot given during the course of a workers' compensation-related injury). These services and expenses would then be excluded from coverage and not eligible for consideration under the workers' compensation plan or the AWCA contract. Some services which are non–compensable under a worker's comp program may be reimbursable under a separate medical benefits plan or may be the responsibility of the patient.

What if I disagree with the repriced amount on my bill?

To question the repricing of a bill, contact the workers' compensation carrier or the third-party administrator responsible for paying the bill. The name and number is located on the explanation of remittance (EOR) you received. The payer will be able to explain how the charges were reimbursed, and if necessary, will resubmit the bill to AWCA for re-evaluation. We have provided a template to use when submitting bills for reconsideration. This may help expedite communication with the payer.

Network Participation

What do I do if I no longer want to participate in the AWCA network?

If you or your group wishes to terminate your participation in the AWCA network, the person with contracting authority for you or your group should call us at 1-800-AETNA-88 (1-800-238-6288). Please provide us with your Aetna provider number and tax identification number. If there’s anything we can do to change your mind, we’d like an opportunity to discuss this with you and would welcome your call. If you decide to opt out of the AWCA network, it will have no impact on your participation in the regular Aetna commercial network.

You may also contact us in writing at this address:

Aetna Worker's Comp Access
151 Farmington Avenue, RT62
Hartford, CT 06156
Attn: Provider Relations Unit

Can I change my mind and re-join the network at a later date?

Yes. If you decide that you want to participate in AWCA after leaving the network, you should call our toll-free AWCA number at 1-800-AETNA-88 (238-6288). We will refer your request to an AWCA network manager assigned to your state, who will contact you directly.

Where are the AWCA networks available?

Please refer to the interactive map section within this website to see a current view of where AWCA has a network available.

Will participation in AWCA affect my participation in other Aetna plans and products?

No.

I became a par provider with Aetna after you invited providers to join your workers' comp network. How can I participate in AWCA?

If you are interested in becoming an AWCA network provider, call AWCA at 1-800-AETNA-88 (1-800-238-6288) to let us know of your interest. A network representative assigned to your state will contact you to discuss your specific situation.

Claimant Information

How do I know what workers' comp coverage the injured worker has?

When the injured worker presents at the provider’s office, the office staff should contact the injured worker’s employer to determine where bills should be sent.

Will my office have to collect a co-payment from an AWCA claimant?

No. There are no co-payments or deductibles to collect.

Will claimants need referrals to receive workers' comp services from me, or will I need to issue a patient referral to another provider?

No. In general, written referrals are not required to treat a claimant. Providers should, however, keep referral patterns to specialists within the AWCA network of available providers for the full spectrum of care to the injured worker. A complete listing of AWCA participating providers is available on this website through the AWCA DocFind® link.

How does the claimant access the AWCA network?

To use the AWCA network, an injured worker must either: a) work for an employer who purchases workers' comp insurance through one of the carriers or customers with whom AWCA has a relationship, or b) be covered by an employer that self-insures its workers' comp coverage and is a customer of AWCA.

Do employers offering Aetna health benefits automatically include workers' compensation benefits with AWCA?

No. AWCA is a separate administrative service that workers' comp insurance carriers, TPAs or self-insured employers can purchase from Aetna. However, there are many employers who purchase an Aetna health plan who are also interested in accessing the AWCA network product for their injured workers.

General Workers' Comp Questions

Who regulates the workers' comp system?

Each state has their own department which has jurisdiction over workplace health and safety and workers' compensation insurance. For example, in some states it is the Department of Labor; in other states it may be the Department of Banking and Insurance, etc.

Does everyone have workers' compensation insurance?

Most states require employers to have workers' compensation insurance for their employees.

Why do employers offer workers' compensation insurance to employees?

In addition to state regulations, having workers' compensation insurance sets limits on an employer's liability arising from workplace accidents. It also provides coverage to help an injured employee get the appropriate medical treatment and return to the job in a timely manner.





 
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