How we build our medical networks
Our network consists of primary care, specialists, hospitals, and other facilities.

We have staff ready to help providers join our network. We want to ensure that members like you have access to the right medical services. We focus our network development on the service area and the type of services offered by the hospitals and affiliated physicians in those areas to make sure that important and essential medical services are available to our members. See how we choose providers below.

Physicians
To be in our network, providers must meet the following:

• Passing our credentialing process
• Working with our medical benefits programs, including preventive care
• Filing claims on behalf of our members
• No balance billing for covered services
• Accepting our fees
• Active admitting privileges in at least one network hospital

Hospitals
To be in our network, hospitals must have a current license and either accreditation by one of the following entities or meet the alternate requirements described below:

• The Joint Commission (TJC)
• The American Osteopathic Association (AOA)
• Det Norske Veritas Healthcare, Inc. (DNVHC)
• An accrediting entity that meets Aetna policy and/or business participation requirements or state/regulatory standards

The groups above perform detailed reviews of hospitals, including onsite visits. They also require hospitals to show quality improvement activities. If a hospital is not accredited, we require an onsite quality assessment. If the Centers for Medicare and Medicaid Services (CMS)/state survey have a similar review process as Aetna, we may substitute the CMS/state survey for an onsite quality assessment.

Our contracts require hospitals to participate in our quality and patient management activities. Facilities must notify us of any material change of licensure or accreditation status. They must maintain adequate general and professional liability insurance or self-insurance, and have proof of insurance upon request.

Every three years our Credentialing team reviews the following for each hospital in our network:

• If they are in good standing with state and federal regulatory bodies;
• If they are accredited by an Aetna-recognized accrediting entity;
• Liability insurance limits
• Medicare certification number, when applicable

More services
We also have participation standards for every type of provider service in our network, including:

• Free-standing surgical centers
• Urgent care centers
• Skilled nursing facilities
• Hospices
• Ambulance services
• Home health care agencies
• Laboratories
• X-ray facilities

Participation criteria may vary based on specialty, market, and applicable local, state or federal laws. Facilities must meet required licensing, certification, professional staffing, access and patient emergency standards. They must also have certain levels of liability insurance. Facilities must also follow patient confidentiality rules.

In general, all network providers must have the proper licensing, education, training, applicable board certifications, and certain levels of liability insurance. They must also have no professional liability claims history or work history that would raise concerns for our members.

Some plans use a performance network. These plans may have other provider selection guidelines.