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Medical - Precertification

Precertification is the process of collecting information prior to inpatient admissions and selected ambulatory procedures and services for the purpose of (1) receiving notification of a planned service or supply, or (2) making a coverage1 determination. Precertification applies to the procedures and services on the Aetna Participating Provider Precertification List; the Aetna Behavioral Health Precertification List Indicates Adobe Reader File Format (1 page); any pre-service coverage request for an advanced coverage decision (organization determination) made by, or on behalf of, a Medicare Advantage member; and those procedures and services requiring precertification under the terms of a memberís plan.

Those services or supplies requiring precertification are included on the ďPrecertification ListĒ referred to below.

Precertification may include a notification process and/or a coverage determination process.

  • The notification process is the recording of a coverage request for services or supplies included on the Precertification List. Notification is only a data-entry process and does not require judgment or interpretation for benefits coverage.
  • The coverage determination process is based upon plan documents and, when applicable, a review of clinical information to determine whether clinical guidelines/criteria for coverage are met.

Note: Benefits and coverage inquiries (defined as any oral or written request for information regarding benefits or services covered under the terms of a specific memberís plan) regarding services not on the Precertification List are not part of the precertification process. Staff is trained to determine whether the caller is making an inquiry or requesting a coverage decision (organization determination) as part of the intake process.

  • Coverage determinations may be based on plan documents and nationally recognized guidelines/criteria. These include:
    • Aetna Clinical Policy Bulletins (CPBs);
    • The Centers for Medicare & Medicaid Services (CMS) guidelines;
    • Milliman Care Guidelines®;
    • The American Society of Addiction Medicine Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition Ė Revised (ASAM-PPC-2R); and,
    • For mental health admissions, the Aetna Level of Care Assessment Tool (LOCAT©)
    • .

    The precertification process facilitates:

    • Communication of a coverage decision to the treating practitioner and/or the member/memberís authorized representative2 in advance of the procedure, service or supply.
    • Identification of members for pre-service discharge planning.
    • Identification and registration of members for covered specialty programs, including Aetna Health ConnectionsSM Case Management, Disease Management, Behavioral Health, National Medical Excellence, and Womenís Health Programs, such as the Beginning Right® Maternity Program.

    Provider and benefits plan applicability
    Precertification applies, as follows, to all benefits plans that include a precertification requirement:
    • The Aetna Participating Provider Precertification List and the Aetna Behavioral Health Precertification List Indicates Adobe Reader File Format(1 page) apply to participating providers. This means that participating providers, not members, are required to pursue precertification when required.

    • A memberís plan may require the member to obtain precertification for certain procedures or services. This requirement applies when it is included in the memberís Certificate of Coverage or Summary Plan Description. A participating provider has no obligation for this precertification requirement.
    Medicare Advantage members and providers on behalf of Medicare Advantage members may request a pre-service coverage determination for any procedure/service that the member believes is covered or should be furnished, arranged for or reimbursed by Aetna.

    For a list of the specific benefits plans to which precertification applies, see the applicable Precertification List.

    • Not all benefits plans are offered in all service areas.

    • For plans with out-of-network benefits (for example, QPOS®, Aetna HealthFund®, Aetna Golden Choice Plan, Aetna Open Access® Managed Choice®, Aetna Choice® POS II and Managed Choice POS), the use of a nonpreferred provider may result in reduced benefits.

    • Medicare Open (PFFS) plans do not require precertification; however, precertification is performed, if requested, for any procedure/service that the member believes is covered or should be furnished, arranged for or reimbursed by Aetna.

    How to submit a precertification request
    Precertification requests may be submitted electronically through an electronic data interchange (EDI), or Internet solution, by telephone, or in writing by fax or mail.

    More stringent state requirements may supersede these requirements.

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    1For these purposes, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.

    2For precertification, concurrent and retrospective reviews, an individual must satisfy at least one of the following requirements in order to be considered an Authorized Representative of a member:
    1. The member has given express written or verbal consent for the individual to represent the memberís interests. A member can appoint an attorney to represent them.
    2. The individual is authorized by law to provide substituted consent for a member (for example, parent of a minor, legal guardian, foster parent, power of attorney); or,
    3. For pre-service, urgent care or concurrent care claims only, the individual is an immediate family member of the member (for example, spouse, parent, child, sibling); or,
    4. For pre-service, urgent care or concurrent care claims only, the individual is a primary caregiver of the member; or,
    5. For pre-service, urgent care or urgent concurrent care claims only, the individual is a health care professional with knowledge of the memberís medical condition (for example, the treating physician).