Wiki Aetna HMO & Referrals to Gynecology - Are Referrals Required or not???

[bbernal]

I am new to gynecology. I am receiving alot of conflicting information from Aetna re: Aetna HMO and the need for a referral for gynecology. Our claims deny for no referral, yet I receive calls from Aetna "concierge" patient representatives telling me that the patient does not need a referral due to Aetna's Direct Access policy.

Can someone confirm for me, that regardless of the reason ( annual, problem, preauth) for the patient's visit - no referrals are required for us as gynecologists???

 

[CBLENNIE]

Are your GYN's contracted specifically with the Aetna HMO plan? If the GYN is PPO contracted but not HMO contracted, then you are going to have issues with the claims submitted for patients who are on the Aetna HMO plan. Additionally, the Aetna HMO plan you are having issues with may be state specific, so you need to be aware of what the state the plan is issued under. The major carriers that have plans in multiple states, often have different coverage guidelines based on each state's coverage mandates and regulations.