Administrative Support

Our administrative management includes expertise in project management, strategic planning and management of various plan operations.

Aetna Medicaid provides efficient, sophisticated, cost-effective operational “back-office” support for our health plans. We have several departments dedicated to operations functions, including:

  • Claims – claims processing, overpayment recovery, rework and cost management.
  • Claims Inquiry-Claims Research (CICR) – handles provider inquiries and online claims reprocessing.
  • Encounters – manages end-to-end encounter processing from the core claim system through submission to state/federal regulators.
  • Operations – oversees policy and procedure maintenance and operations reporting.

Aetna Medicaid’s Provider and Network Services is the primary contact for hospitals, physicians and other providers who are participating in or would like to participate in our networks. This team leads provider contracting and network development for our current health plans and builds provider networks for new health plans. It acts as a liaison to the health plan for contracted providers. It also works to educate, problem solve and provide answers and assistance to providers so that they can more effectively serve our members. 

Our health plans have local dedicated teams to lead ongoing network management, helping Aetna Medicaid’s members get access to a comprehensive, robust network of providers.  Our Provider Services team consists of individuals assigned to high-volume providers such as hospitals. They are available to answer questions about credentialing, claims and other topics from all providers, both in- and out-of-network.

Customer satisfaction is a differentiating factor for our health plans. Our Member Services team provides best-in-class customer service. This includes responding to member inquiries, sending checkup and inoculation reminders, providing initial and ongoing wellness education, assisting with appointment scheduling, and developing member handbooks and member surveys.

Aetna Medicaid’s Information Technology capabilities include a 24-hour data center, electronic data interchange, network and database administration, advanced telecommunications systems and management reporting.

In addition, we have state-of-the-art public websites that feature responsive design for easy navigation across devices, intuitive navigation and full accessibility for people with disabilities. We also offer secure portals for members and providers to check claims status, request prior authorization, access reports, and more.

For more, check out Technology Solutions.

Aetna Medicaid Compliance is responsible for managing the compliance program. The program is intended to prevent, detect and correct illegal, improper or unethical conduct impacting our health plans. The department works in close cooperation with Aetna’s compliance organization, health plan compliance staff and legal counsel. Team members review business activities and identify risks and legal requirements applicable to our health plans, as set forth by the two federal agencies governing compliance programs: The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG). Promoting the values of compliance, ethics and integrity as the responsibility of every employee, the team helps employees work through compliance challenges and determine how to "do the right thing." 

Aetna Medicaid’s Actuarial Services include trend analysis, reserve development and budget projections. This team also develops and evaluates rate setting for both new and existing health plans by projecting historical claims and administrative experience to reflect trends, benefit changes and population shifts.  Additional activities include the evaluation and development of mitigation strategies for changes in health care regulation and financing.

Our Learning and Performance team provides new hire and functional training to employees supporting the needs of the organization both operationally and clinically. The team delivers and develops training by offering instructor-led courses, technology-based training and short-system vignettes. Functional training courses range from clinical case management and long-term support services to claims, member and provider services training. All new employee training includes an orientation to Aetna Medicaid, as well as continuing education for existing employees, which may be regulatory or performance based.