1-6 | Table of Contents | Pages 1 through 6 include links that take you to the page the indicated article is on. Page 1 has two highlighted articles for September that are located below with their respective topic. - Page 22 has an article about digital prior authorization
- Page 24 has information about referrals to in-network pharmacies
| ALL |
7-10 | Important policy updates (including pharmacy) Payment and coding - Claim and Code Review Program Update
- Maternity care services coding restructure
| Aetna® ® is required to notify of any change that could affect either financially or administratively at least 90 days before the effective date of the change. This change may not be considered a material change in all states. Unless otherwise stated, policy changes apply to both Commercial and Medicare lines of business. Note to Texas providers: Changes described in this article will be implemented for fully insured plans written in the state of Texas in accordance with regulatory requirements. Changes for all other plans will be as outlined in this article Claim and Code Review Program (CCRP) update - Beginning December 1, 2026, you may see new claim edits. You can view these edits on the provider portal on Availity.
- For coding changes, go to Aetna® Payer Space > Resources > Expanded Claim Edits.
- Except for Student Health, you'll also have access to the code edit lookup tools.
- This update applies to commercial and Medicare members
Maternity care services coding restructure - Effective January 1, 2027, The AMA and the American College of Obstetricians and Gynecologists (ACOG) are replacing the global maternity CPT® codes with Evaluation and Management services codes for antepartum and post-partum care, new labor management codes and updated delivery codes.
- Aetna is working to implement these codes and is committed to communicating these implementation updates to you as soon as they’re available.
| Claims Coding Patient Access Physicians |
10-11 | Important policy updates (including pharmacy) Pharmacy and formulary - Changes to commercial drug lists begin on January 1st
- Important pharmacy updates
| Upcoming changes to commercial drug lists - On January 1, 2027, Aetna will update their pharmacy drug lists. These changes may include:
- Adding or removing specialty, brand-name and generic drugs
- Changing preferred or non-preferred drugs
- Changing PA, quantity limits and step-therapy requirements
Important pharmacy updates: | Claims Coding Patient Access Physicians |
12-19 | State-specific updates (Texas only) - Identifying chronic conditions
| How to verify that your patient has a chronic condition - You are now able to use the automated phone system (1-800-624-0756) to verify a patient’s chronic condition, as required by CMS.
| Patient Access Prior Auth Physicians |
19-20 | News for you Education and Onboarding - Provider onboarding webinar
| New Provider onboarding webinar for providers and their staff - Take “Doing business with Aetna” New provider onboarding webinar to get lots of your questions answered offered on second Tuesday and Third Wednesday of every month from 1PM to 2:30PM ET.
| Office Staff Physicians |
20-22 | News for you Electronic transactions - Digital submissions can speed up claims processing
- See more commercial claim details in your ERA
| How digital submissions can speed up claims processing and dispute resolution - These tools are built to support your workflow and make it easier to submit claims and disputes. Log in to Availity to get started.
- View article for more details.
See more commercial claims details in your ERA - Beginning in early August 2026, your Electronic Remittance Advice (ERA) began showing more details for some commercial claims when Aetna needed more information
| Office Staff |
22-23 | News for you Electronic transactions - Digital prior authorization can help your practice
| Digital prior authorization (PA) can help your practice - Activate digital PA functions within your HER system.
- View article for more details.
| Office Staff |
24-26 | News for you Plans and Programs - 2026 HealthFund plan HRA
- Non-pharmaceutical interventions (NPIs)
- Check your APCN status for 2027
| Aetna HealthFund (AHF) plan Health Reimbursement Account (HRA) - The AHF HRA is a national reimbursement account, or health fund, that accompanies some medical health plans. Health funds pay toward a member’s deductible until it’s met.
- View the article for more details.
Non-pharmaceutical interventions (NPIs) - Please encourage members to review their Official Plan Brochures for information on available benefits when appropriate.
Check your Aetna Premier Care Network (APCN) status for 2027 | Office Staff Physicians |
23-24 | News for you Policy and practice updates - AI-powered chat on Aetna.com
- Refer patients to in-network pharmacies
| Get answers faster with the new AI-powered chat on Aetna.com - Quick answers: Get general information about claims, appeals, billing, prior authorization, network participation, forms, and CPT codes – no login required.
- View article for more details
Remember to refer patients to in-network pharmacies | Claims Office Staff Physicians |
28-31 | News for you Quality Management - Aetna office manual keeps you informed
- Improving the patient experience
- Work with us to support your patients
| Aetna office manual keeps you informed Improving the patient experience - Each year, Aetna sends a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to gather feedback from members about their overall health care experience, including their experience with their personal doctor.
Work with us to support your patients - Aetna’s care management (CM) programs support you by identifying high-risk members and sharing care information. You’re asked to incorporate this information into treatment planning and collaborate closely with care managers to ensure timely, coordinated care across settings.
| Patient Access Physicians |
32-36 | Behavioral Health Quality Management - Behavioral health clinical criteria
- Behavioral health quality management program summary
- Depression care program
- SBIRT
| Behavioral health clinical criteria - Read about how Aetna determines coverage and where to get more information
2026 Aetna behavioral health quality management program summary - Read about how Aetna is making improvements on service, quality, and safety of behavioral health care.
Depression in primary care program - Read about how to screen for depression during a primary care visit and billing procedures.
Use Screening, Brief Intervention and Referral to Treatment (SBIRT) in primary care - Read about how to screen for risky alcohol or substance use and intervention during a primary care visit and billing procedures.
| Behavioral Staff Physicians |
36-39 | Medicare | SWHR is no longer contracted with Aetna Medicare | |
