Provider Directory - Aetna Medicare
Provider Directory - Aetna Medicare
Provider Directory - Aetna Medicare
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Section 1 – Introduction<br />
This directory provides a list of <strong>Aetna</strong> <strong>Medicare</strong> (HMO)<br />
(PPO) plan providers. To get detailed information<br />
about your health care coverage, please see your<br />
Evidence of Coverage.<br />
With the standard <strong>Aetna</strong> <strong>Medicare</strong> Health<br />
Maintenance Organization (HMO) plan you will<br />
have to choose one of our plan providers that are<br />
listed in this directory to be your Primary Care<br />
Physician (PCP). The term “PCP” will be used<br />
throughout this directory. Generally, you must get your<br />
health care coverage from your PCP.<br />
The “plan providers” listed in this directory have<br />
agreed to provide you with your health care coverage.<br />
You may go to any of our plan providers listed in this<br />
directory, however some services may require a<br />
referral. If you have been going to one plan provider,<br />
you are not required to continue going to that same<br />
provider. In some cases, you may get covered services<br />
from non-plan providers. In cases where noncontracting<br />
providers submit a bill directly you, you<br />
should not pay the bill, but submit it to <strong>Aetna</strong><br />
<strong>Medicare</strong> for processing and determination of your<br />
financial liability, if any. Your PCP will issue referrals to<br />
participating specialists and facilities for certain<br />
services. For some services, your PCP is required to<br />
obtain prior authorization from <strong>Aetna</strong>. You must use<br />
network providers except for urgent care or out-of<br />
area urgent care/renal dialysis. Except for those<br />
benefits described in your plan documents as directaccess<br />
benefits, or in an emergency, you will need to<br />
obtain a referral from your PCP before seeking covered<br />
non-emergency specialty or hospital care. Check your<br />
Evidence of Coverage for details.<br />
With the <strong>Aetna</strong> <strong>Medicare</strong> Open Access (HMO)<br />
plans, you are not required to choose a primary care<br />
physician (PCP) and are free to visit network providers<br />
without a referral to receive covered services.<br />
Although selecting a PCP is not required, you will<br />
benefit by receiving care from a doctor that has a<br />
deeper understanding of your health care needs and<br />
may be able to assist with important medical<br />
decisions.<br />
With the <strong>Aetna</strong> <strong>Medicare</strong> Preferred <strong>Provider</strong><br />
Organization (PPO) Plan, you have the flexibility to<br />
choose either network providers at lower out-ofpocket<br />
costs, or out-of-network providers at a higher<br />
cost sharing level. If you select a PCP from our<br />
network, you must notify us of your selection in order<br />
to have the lower primary doctor visit copay. By having<br />
a PCP coordinate your care, you’ll also benefit by<br />
receiving care from a doctor that has a deeper<br />
understanding of your health care needs and may be<br />
able to assist with important medical decisions. Note:<br />
If you do not select a PCP, you’ll be responsible for the<br />
higher specialist copay when receiving services from a<br />
PCP.<br />
Certain healthcare services, such as hospitalization or<br />
outpatient surgery, require precertification with <strong>Aetna</strong>.<br />
This means the service must be approved by <strong>Aetna</strong><br />
before it will be covered under the plan. Check your<br />
Evidence of Coverage for a complete list of services<br />
that require this approval. When you are to obtain<br />
services requiring precertification from a participating<br />
provider, the provider is responsible to precertify those<br />
services prior to treatment. If your plan covers out-ofnetwork<br />
benefits and you may self-refer for covered<br />
services, it is your responsibility to contact <strong>Aetna</strong> to<br />
precertify those services which require precertification.<br />
If you need emergency care, you are covered 24 hours<br />
a day, 7 days a week, anywhere in the world. Whether<br />
you are in or out of an <strong>Aetna</strong> <strong>Medicare</strong> service area,<br />
we simply ask that you follow the guidelines below<br />
when you believe you need emergency care.<br />
■ Call the local emergency hotline (ex. 911) or go to<br />
the nearest emergency facility. If a delay would not<br />
be detrimental to your health, call your PCP. Notify<br />
your PCP as soon as possible after receiving<br />
treatment.<br />
■ If you are admitted to an inpatient facility, you or a<br />
family member or friend on your behalf should<br />
notify your PCP or <strong>Aetna</strong> as soon as possible.<br />
If you are traveling outside of the <strong>Aetna</strong> <strong>Medicare</strong><br />
(HMO) (PPO) plan service area, you are covered for<br />
emergency and urgently-needed care. Urgent care<br />
may be obtained from a private practice physician, a<br />
walk-in clinic, an urgent care center or an emergency<br />
facility. If, after reviewing information submitted to us<br />
www.aetnamedicare.com<br />
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