CommercialReimbursementHigh impact
OfficeLink Updates - January 2025 notices and reminders (PDF)
Aetna·Pulmonology, Neurology, Pain Management·Newsletter
Effective date
Apr 1, 2025
We identified it
Jun 23, 2026
Summary
Aetna is implementing multiple billing changes effective April 1, 2025, including reducing reimbursement for nurse practitioner/midwife services to 85%, requiring CPAP adherence documentation for reimbursement, and removing precertification requirements for certain neurostimulator devices and Skyrizi injections. Drug formulary changes will also take effect with proactive prior authorizations issued.
Action Required
By April 1, 2025: Billing team must update system to pay SA/SB modifier claims at 85% of allowed amount instead of 100%. For CPAP claims, require adherence codes G8851, G8854, or G8855 on all claims or they will be denied. Remove precertification requirements for codes J2327, C1767, C1816, C1820, and C1822. By February 1, 2025: Review Medical Clinical Policy Bulletins page for drug formulary changes and update prior authorization workflows accordingly.