Fall

REQUIREMENTS: (1) Billing and clinical teams: Begin systematically documenting social determinants of health using ICD-10 Z codes (Z55-Z65) for all member encounters across all specialties. Add SDOH screening questions to encounter intake forms and EMR templates. Train clinical staff that any care team member can collect SDOH data during patient visits. (2) Prior authorization and billing staff: Review and apply UM/prior authorization criteria in the following hierarchical order: state/federal regulatory requirements first, then MCG guidelines, Aetna Medicaid Pharmacy Guidelines, Level of Care Utilization System (behavioral health), American Society of Addiction Medicine criteria (substance use), Aetna Clinical Policy Bulletins, and Aetna Clinical Policy Council reviews. Verify your billing system applies criteria in this exact order. (3) Providers: For diabetic members aged 18-85, ensure KED HEDIS measure compliance by documenting both estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR) during the measurement year. (4) All staff: Confirm interpreter services phone number (1-800-385-4104, TTY: 711) is available for telephonic interpretation same-day requests and request other formats at least three business days in advance. Document language preferences in member records. (5) Billing team: Review current formulary on AetnaBetterHealth.com/Virginia before processing prescriptions to identify any restrictions or recommendations that may affect claims processing.