Utilization Management
How we determine coverage
Guidelines for coverage determination
Coverage determination is based on recognized guidelines or criteria that include:
- Aetna’s Clinical Policy Bulletins
- Centers for Medicare & Medicaid Services National Coverage Determinations, Local Coverage Determinations And Medicare Benefit Policy Manual
- MCG™ (Seattle, WA:MCG Health, LLC)
- American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders (ASAM PPC-2R)
- Texas Commission on Alcohol and Drug Abuse regulations (used in place of ASAM for Texas members)
- Applied Behavioral Analysis© (ABA) Guidelines for the Treatment of Autism Spectrum Disorders
- Level of Care Assessment Tool© (LOCAT) for behavioral health admissions
Outside Vendors
In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors.
Concurrent review
Sometimes utilization management takes place during inpatient care or outpatient treatment.
Retrospective review
In a retrospective review, coverage is determined after treatment has occurred.
Note: More stringent state requirements may supersede the requirements of this policy.
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