08/18/2025

Aetna

Aetna's August 2025 OfficeLink Update
The full update can be found HERE. Below are a few articles that may be relevant to you:

• Level of Severity Inpatient Payment Policy
• New reporting requirements for benign and malignant integumentary lesion excisions
• Changes to our National Precertification List (NPL) - Effective August 1, 2025

Level of Severity Inpatient Payment Policy
This policy applies to all participating Medicare facilities that have a Medicare allowable payment methodology and that participate in Aetna Medicare Advantage and/or Special Needs Plans (SNPs). This policy applies to emergent or urgent inpatient stays that are greater than one midnight (1+ midnight).

The new payment structure for Medicare inpatient claims
Our goal is simple: We want to help you get reimbursed faster for inpatient admissions that are initially denied.You'll receive faster payment and still be allowed to appeal for a higher payment.

Effective November 15, 2025, we’ll adopt a new reimbursement approach for hospital stays of 1+ midnight in cases where a member is urgently or emergently admitted to a hospital and the provider has submitted an inpatient order.

• We’ll approve the inpatient stay without a medical necessity review and pay the claim at a lower level of severity rate that’s comparable to your rate for observation services.**
• If the inpatient stay meets MCG (Aetna Supplemental Guidelines for inpatient admissions), we’ll pay the claim at your inpatient rate in accordance with the hospital agreement.

Notes and exceptions

• We won’t use MCG to determine whether an inpatient stay is medically necessary. Instead, we’ll use it to determine the severity of an inpatient admission and whether that severity justifies the inpatient contracted rate.
• This policy doesn’t apply to stays that are less than 1 midnight. Cases that are less than 1 midnight will still be subject to medical necessity reviews using Centers for Medicare & Medicaid Services (CMS) guidelines.

How this reimbursement change helps you
We’re committed to streamlining, simplifying, and enhancing how you work with us.

• This new structure will pay you faster. Currently, we deny a stay that doesn’t meet MCG, requiring you to either resubmit a claim for observation or submit an appeal to receive the inpatient contracted rate. Now, you’ll get paid faster without having to re-bill claims for 1+ midnight stays that don’t meet MCG.
• You maintain your right to dispute the inpatient reimbursement rate.

More information
The payment policy will be available on our provider portal on Availity in October.*