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Q. Why did the Southern New Jersey Health Insurance Fund choose Aetna as the provider network? A. Aetna has one of the largest Provider Networks in Southern New Jersey.
Q. What is Utilization Review? A. Aetna reviews specific services to evaluate the appropriateness, necessity and quality of health care. This review allows the patient to be more involved in the plan and delivery of treatment. The review uses established criteria and standards that addresses not only the plan of treatment, but also the monitoring of continued treatment. Utilization Review includes: pre-certification of hospital admissions and elective surgery, concurrent hospital review and discharge planning, second surgical opinion when appropriate, high risk pregnancy, and large claim management.
Q. What is Pre-Certification Review? A. The physician or patient usually pre-certified for the following:
Non-emergency hospital admission at least seven (7) business days in advance of the scheduled admission.
Emergency admission within 48 hours or by the next business day following admission.
For maternity submissions during the first trimester and within one day following hospitalization.
Specific services as outlined in the Plan Document.
The participant should always check with the Plan Document to determine if pre-certification is required as well as the Plan’s parameters.
Q. If I have the Patriot X Plan, must I use the Aetna Provider Network? A. No, you always have the freedom of choice regarding the providers you used. Most claims are subject to your plan’s annual deductible and co-insurance. HOWEVER, if you use an Aetna Provider, your out-of-pocket expense is less.
For example:
**If the out-of-network provider fee is $1,400 reasonable and customary and you have a $100 deductible and 20% co-insurance, your out-of-pocket expenses is $360.00 ($100 deductible plus the 20% of the $1,300 balance). If you use an in-network Aetna provider, that same procedure may be $800.00. You would still pay the $100 deductible, however, your co-insurance would be $140 (20% of $700), so your total out-of-pocket expense would be $240. This would provide you with an out-of-pocket savings of $120 for the same procedure.
Q. What if the out-of-network provider charges more than what is the Reasonable and Customary fee; what are my expenses? A. For All Plans beside the deductible and co-insurance, you will be responsible for any fees charged by the Provider over and above the Reasonable and Customary charges. The major advantage of using an in-network provider is there is no balance billing.
Q. What if my Primary Care Physician is not in the Aetna Network? A. Please let your benefits administrator or FUND representative know that your Primary Care Provider is not in the network. Aetna will contact your provider about joining the network. The decision regarding network participation is between the provider and AetnA.
Q. What do I tell my Provider when the office asks who my insurance carrier is? A. Southern New Jersey Regional Employee Benefits Fund
Q. Who will pay my eligible benefit claims? A. The Southern New Jersey Regional Employee Benefits Fund pays the claim for eligible benefits. The FUND contracts with Aetna to process the claims and send the payments.
Q. What if I need to see a specialist for a specific procedure and there are not any specialists geographically close to me or there is a specialist out of the network who is the only provider to perform the procedure? A. Utilization Management will review the procedure and its benefit to you. Upon review, if it is determine this particular physician and procedure is beneficial to you and it is a covered benefit and no other provider is available to you in network, this claim will be paid as though in-network at reasonable and customary charges. You would be responsible for those fees over and above the reasonable and customary fees.
