Radiology and other outpatient imaging services: Precertification and claims processing
We have delegated responsibility for precertification and/or claims processing of certain diagnostic imaging services to a third-party vendor, CareCore National (CCN). This is for our HMO-based plans (including Medicare), Health Network Option and Health Network Only plans. They are collectively referred to as Aetna Health Network, PPO-based and Medicare Advantage (except for Medicare fee-for-service) plans.
Unless we otherwise note, use the location of the primary care physician’s (PCP) office to:
- Decide if the vendor is responsible for precertification.
- Know where to send the claim (to the vendor or us).
If the member doesn’t have a PCP, you can determine the above based on where the member lives. CCN’s geography includes these counties:
- Staten Island
We require pre-approval from CCN for the following outpatient services:
- Radiology imaging
- Sleep studies
- Cardiac imaging
- Cardiac implants
- Radiation oncology
Note: There are certain Aetna HMO-based, PPO-based, Aetna Health Network and Medicare Advantage plan sponsors that ask to be excluded from CCN's utilization management and claims processing program. PPO-based plan sponsors have to opt in to CCN's programs, and there is not currently a listing of PPO-based plan sponsors that are excluded.
Tips to remember
- Check eligibility for PPO-based members.
- You can find a list of excluded plan sponsors for Aetna HMO-based, Aetna Health Network and Medicare Advantage plans here (PDF, 19 KB).
- You don’t need to contact CCN for precertfication for members who are part of a plan sponsor who we exclude from CCN.
- You should send claims for plan sponsors who we exclude directly to us.
- Aetna medical review guidelines will apply for all claims that you send to us.
- Providers must follow our standard Clinical Claim Review referral guidelines.
Send to Aetna:
- All claims for services from providers not contracted with either CCN or Aetna.
- All claims for imaging services provided as part of an inpatient stay, in a hospital emergency department, part of an ambulatory surgery procedure, or performed at an urgent care center.
- All claims under PPO and Medicare plans.
- All claims under high-deductible health plans, including but not limited to High Deductible Health Plans that are part of a flexible savings account (FSA) or health savings account (HSA).
- All member claims for excluded plan sponsors (PDF, 19 KB) from CCN's precertification program).
Send to CCN:
- HMO-based and Aetna Health Network plans where the provider is contracted with CCN, and the member’s claim is not on the “Send to Aetna” list above.
- HMO-based and Aetna Health Network claims falling within the 70,000 series. This excludes radiation oncology, therapeutic nuclear medicine, ophthalmic ultrasounds and preadmission test codes.
Fax: 1-888-444-1562 (sleep studies only)
CareCore: CareCore Policies & Payment Rules