New Jersey Providers

Radiology and Imaging Services: Precertification and Claims Processing

Aetna has delegated to a third party vendor responsibility for Pre-certification and/or Claims Processing of certain radiology, imaging and related services, under our HMO, PPO and Medicare (except for Medicare Fee For Service) products.

 Please Note: Except as otherwise indicated, whether the vendor is responsible for pre-cert, and whether the claim should be sent to the vendor or to Aetna, is determined by the location of the Primary Care Physician’s (PCP’s) office; if the Member does not have a PCP, it is determined by the Member’s residence.

PCP’s office, or if there is no PCP the Member’s residence, located in a county in Northern New Jersey (Bergen, Essex, Hudson, Hunterdon, Middlesex, Monmouth, Morris, Ocean Passaic, Somerset, Sussex, Union, or Warren) ….

Precertification 

Contact CareCore National (CCN) for precertification of

• High Tech Radiology
• Cardiac Imaging
• Sleep Studies
• Radiation Oncology

Note: Some Plan Sponsors have elected not to participate  (PDF, 28 KB) in CCN’s precertification program.

 Claim Submission 

Submit to Aetna:

• All claims for services of providers not contracted with either CCN or Aetna
• All claims for services of providers located in a county in Southern New Jersey
• All claims for hospital-based services
• All claims under PPO plans
• All claims under High Deductible Health Plans, including but not limited to HDHPs that are part of an FSA or HSA.
• All claims of Members whose Plan Sponsor has elected not to participate  (PDF, 28 KB) in CCN's precertification program.

Submit to CCN:

• HMO claims where the provider is contracted with CCN and the member’s claim is not on the “Submit to Aetna” list above
• HMO claims falling within the 70,000 series with the exception of radiation oncology, therapeutic nuclear medicine, ophthalmic ultrasounds, and pre-admission test codes

PCP’s office, or if there is no PCP the Member’s residence, located in a county in Southern New Jersey (Atlantic, Burlington, Camden, Cape May, Cumberland,   Gloucester, Mercer, or Salem)

Precertification

Contact MedSolutions for precertification of

• High Tech Radiology
• Cardiac Imaging
• Sleep Studies

Claim Submission

Submit all claims to Aetna

Contact Information

CareCore National
Phone: 1-888-647-5940
Fax 1-800-540-2406
Fax 1-888-444-1562 (sleep studies only)
Website: www.carecorenational.com

MedSolutions
Phone: 1-888-693-3211
Fax: 1-888-693-3210
Website: www.medsolutionsonline.com

New Jersey Claim Form - “Health Care Application to Appeal a Claims Determination

Aetna: http://www.aetna.com/provider/data/NJ_prov_appeal_proc.pdf  (PDF, 21 KB)

CareCore: http://www.carecorenational.com/carecore-claims-payment-policies-and-rules.asp