CMS says:
"
New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years.
Established Patient: An individual who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years. "
My local MAC (
Noridian) helps by making this a little clearer (website with good examples too!):
"New Patient
Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.
For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation."
Now, I couldn't find Aetna's E/M policy, but I would be very surprised if they decided to deviate too much on that sense.
Possible reasons for the denial:
-The patient was seen by the same provider at a previous practice, within 3 years
-The patient was seen by a similar credentialed provider from the same practice (fairly common denial reason)
Remeber that all NPs are considered credentialed as Family Practice/Medicine and Nurse Practitioner (50), and are credentialed the same as other NPs
regardless of their individual specialty (applies only to NPs though).
Without knowing additional details, it can be difficult to speculate other scenarios.
Hope this is helpful.
Additional readings: