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Medical - Change in Reimbursement Policy for Non Par Behavioral Health Providers for PPO-based and HMO/QPOS plans

Beginning with dates of service on or after September 1, 2006, in PPO-based and HMO/QPOS plans, Aetna is changing our reimbursement policy for nonparticipating behavioral health providers. This change ties reimbursement to the level of the licensure of the clinician and will result in a change in Aetna's reimbursement for nonparticipating psychologists and social workers. This change will not affect psychiatrists and does not apply to the Medicare Advantage product or members covered by insured New Jersey Small Group and Individual Plans.

Effective September 1, 2006, this change will reduce the allowable amount to:
  • 80% of Usual and Customary Rate (UCR) for psychologists

  • 60% of UCR for social workers
Reimbursement will be further subject to applicable plan deductible, coinsurance and/or copayment.

This new policy makes our approach to reimbursement for nonparticipating behavioral health providers consistent with our approach for Aetna participating behavioral health providers.

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