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Aetna Tiering FAQ

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Is Stanford Healthcare a Maximum Savings Provider for labs, imaging, and physical therapy?

Stanford Healthcare (SHC) is categorized as a Standard Savings provider rather than a Maximum Savings provider. However, they are part of the Aetna in-network. You can still receive services at SHC, though your expenses may be higher compared to using a Maximum Savings provider. If needed, you can ask your Stanford provider to send your lab order to Quest or give you the lab order to take to LabCorp.

How will Stanford Healthcare or Palo Alto Medical Foundation receive my lab or imaging results if I do not use them for these services?

Stanford Healthcare (SHC) and Palo Alto Medical Foundation (PAMF) use EPIC to manage their electronic medical records. If the Maximum Savings provider you use also uses EPIC, the results can be transferred electronically. LabCorp and Quest also have apps you can download and receive any lab results. Imaging centers can provide the imaging results that you can send to your provider for review.

Do I need a referral to see a specialist if I am enrolled in the Stanford Select Copay Plan or Stanford Choice High Deductible plan, and does tiering apply to the doctors I see?

A referral to a specialist is not required for the Select Copay or Choice High Deductible plans. Tiering only applies to labs, imaging, and physical therapy and not to providers, urgent care, or emergency room use.

Where can I find information on Maximum Savings and Standard Savings providers?

Review the Maximum Savings Guide on Cardinal at Work to help you find a provider.  

If I use a Stanford Healthcare or Palo Alto Medical Foundation provider for my routine annual preventive exam, how are labs and imaging services covered?

Tiering for labs and imaging does not apply to preventive services that are part of your annual check up even if your preventive services are provided through Stanford Healthcare or Palo Alto Medical Foundation. However, the services need to be billed as preventive to be covered 100% by the plan.

If I require services to monitor a prior health issue (whether imaging or labs), why aren’t these considered preventive services during my annual check-up?

Preventive services are those typically delivered during a routine annual exam. That does not include services to monitor a known health issue or health concerns raised during your exam. For example, if your provider does a biopsy of a skin area because of concern it could be cancerous, that biopsy is a diagnostic service and not billed as part of your preventive check-up.  A mammogram for a woman with a recent diagnosis of breast cancer to monitor if it has recurred is not a preventive imaging service; it is diagnostic and would be billed that way.