Effective January 1, 2007, Aetna Will Consider Resubmitted Claims for E&M Visits Appended by a Modifier 57

Effective January 1, 2007, Aetna will consider resubmitted claims that were originally submitted with an evaluation and management (E&M) visit appended by a Modifier 57 (when the visit is performed in conjunction with a major surgical procedure). This consideration applies to claims for dates of service from January 1, 2005 through February 11, 2006. This resubmission period will begin on January 1, 2007 and extend through April 30, 2007.

Background
In October 2006, Aetna decided to reconsider claims for previously denied services related to E&M visits appended by a Modifier 57. This change stemmed from open and collaborative discussions with several state medical societies and individual medical groups to clarify this issue and to come to an understanding, given varying interpretations of the Physicians Settlement Agreement.

Guidelines for claims resubmission
Any physician who has not opted out of the Settlement Agreement may resubmit claims for an E&M visit when the decision for surgery was made, and the claim was denied by Aetna. The dates of service for which claims may be resubmitted are January 1, 2005 through February 11, 2006. Please note that Aetna had previously allowed physicians to resubmit these claims with dates of service from August 15, 2005 through February 11, 2006 -- physicians who have already resubmitted claims for these dates of service may not resubmit them again.

Physicians can resubmit claims by completing an electronic spreadsheet and submitting it via secure e-mail to designated mailboxes. The process, spreadsheet and mailboxes are provided on the Aetna.com website under “Resubmission of Claims for E&M Visits at Which Decision for Surgery Was Made.”

As part of the resubmission process, physicians will be required to certify that the resubmitted claims were not previously paid by Aetna. It is important to note that Aetna will not accept resubmissions via written correspondence, paper claims or the spreadsheet in paper format.

All payments made by Aetna will be consistent with member benefits plans, including deductibles and coinsurance. Aetna will issue an Explanation of Benefits to the physician detailing the payments and the rationale for each determination. No interest or late payment penalties will be assessed against Aetna. Any nonparticipating physician who has billed his or her patients must agree to refund patients promptly when total payments exceed charges and create a credit balance to the patient. Download the Modifier 57 Claim Form