female doctor speaking with patient

Utilization Management

How we determine coverage

male nurse with elderly female patient

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

Learn more about LOCAT and ABA

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Outside Vendors

In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors.

CareCore National
MedSolutions
OrthoNet

Concurrent review

Sometimes utilization management takes place during inpatient care or outpatient treatment.

Learn more about concurrent review

Retrospective review

In a retrospective review, coverage is determined after treatment has occurred.

Learn more about retrospective review

Note: More stringent state requirements may supersede the requirements of this policy.

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