Accurately following third-party insurer guidelines is an essential part of DME billing success. Failure to comply with the guidelines will result in claim denials and delayed payments. As a DME supplier, you’ll eventually have to submit claims to the insurer Aetna. As a large company, Aetna serves Medicare, Medicaid and Commercial Lines of business and helps to ensure they receive the care and supplies they need to live better healthier lives.
To help you submit clean claims, we’ll provide you with a brief overview of what to expect by answering common questions about Aetna’s DME billing guidelines. We’ve provided Aetna’s Medicaid coverage in Florida as an example, but please keep in mind that the rules in every state vary.
And as a reminder, you can always contact them directly with your concerns (details on how to reach Aetna are at the end of this article).
What Are Aetna’s DME Billing Guidelines?
While we can’t give you a simple answer to your question, we break down some of the main components of Aetna’s DME billing guidelines in the questions below to help improve your understanding of it. So keep reading, and we’ll share other credible information sources to help you learn more about their guidelines for billing DME.
What Types of DME Items Will Aetna Reimburse?
They will reimburse certain DME items and supplies that patients need to purchase, rent for a specific period, or opt for a rent-to-purchase plan.
While this isn’t a comprehensive list, some of the DME items Aetna will provide reimbursement for includes:
- Diabetic equipment and supplies
- Blood glucose meters
- Test strips
- Enteral nutrition supplements
- Mobility equipment
- Orthotics and prosthetic devices
- Respiratory equipment and supplies
- Suction pumps
- Toilet chairs (commodes)
Can You Explain the DME Pricing, Coding, and Limits for Aetna?
Aetna is a nationwide company, serving customers across all fifty states. While this provides beneficial infrastructure, it comes with some necessary complexity as well. Because healthcare requirements and resources vary state by state, so too do Aetna’s guidelines.
For the purposes of this article, we’ll focus on the state of Florida as our example. Please note that the following applies only to Medicaid.
In the state of Florida, Aetna follows the state’s Agency for Health Care Administration (AHCA) fee schedules to determine the reimbursement amount for DME services. Any codes that don’t have an assigned rate will reimburse according to the invoice plus 15%.
Depending on your state, the specifics of Aetna’s DME pricing, coding, and limits may vary. You can view the guidelines relevant to your own location on Aetna’s website.
What Are the Order Requirements for DME Coverage with Aetna?
The DME items and supplies must meet specific necessities to receive reimbursement.
- The patient must show paperwork expressing their need for the item(s)
- Doctor notes in the patient’s chart
- Hospital discharge orders
- The above documents must include the provider’s signature and date
- The above documents also need to include the following:
- Length of use
- Patient diagnosis
- The specific term of use
- Items that patients can use in their homes and are:
When Is Prior Authorization Necessary?
Aetna provides a tool that you can use to learn what items need prior authorization. You can access that tool here. Keep in mind that rules may vary from state to state, so check with your state’s health laws to find the information you’re looking for.
For an example, we’ll provide information on Aetna’s Medicaid coverage in Florida. In this state, prior authorization is necessary for:
- Purchases over $500
- All rental items
- Any equipment not listed on the fee schedule
What Is Aetna’s Processing Time for DME Claims?
Please note that to receive the fastest response, all claims should be submitted electronically. Rules from state to state may vary, so check with your regional Aetna representative for the most accurate information.
First Response Within 24 Hours
They’ll send you a confirmation receipt that the claim was successfully submitted.
Second Response Typically Within 15 Days
Next, you’ll receive confirmation of claim payment or notification of claim denial. If Aetna denies your claim, they will include the reasons for the denial and what you’ll need to do to resubmit it.
Final Response Typically Within 90 Days
You’ll receive a claim payment. If you don’t receive payment or notification of claim denial, contact them as soon as possible. Once 120 days from the first submission, you can no longer contest payment for the claim.
Are There Reliable Sources for Learning About Aetna’s Guidelines on Billing DME?
Yes, below are some Aetna PDF documents and web pages that can help you learn more about their DME billing guidelines.
- Billing and Claims Quick Reference Guide
- Aetna’s Provider Manual
- In-Depth Details on Prior Authorizations
- Billing and Coding Questions For COVID-19
If you need to contact Aetna, they have specific contact information for each state. Find your state’s contact information here.
Learn How Medbill Can Help You with Aetna’s DME Guidelines
If you need additional help submitting claims or managing denials or want someone else to handle your DME billing needs, Medbill is your solution! We’re a full-service DME billing company with a team of experts who know everything related to DME billing.
Contact us to learn how we can help you with Aetna’s DME billing guidelines, increase your claims approval rates, and more!