Behavioral health services requiring precertification*/authorization

Precertification: How and when?

To get precertification/authorization for mental health, behavioral health or substance abuse services: 

• Refer to the member’s ID card for the toll-free Member Services or Aetna Behavioral Health phone number.
• Check the list of services below that may require precertification, subject to the member's plan of benefit coverage requirements.
• Use the Level of Care Assessment Tool (LOCAT) or ASAM Patient Placement Criteria, Second Edition-Revised (ASAM PPC-2R) to assess the appropriate level of care.

Applies to:

Aetna Choice POS®, Aetna Choice® POS II, Aetna Medicare^SM Plan (PPO), Aetna Medicare^SM Plan (HMO), all Aetna HealthFund® products, Aetna Health Network Only^SM, Aetna Health Network Option^SM, Aetna Open Access® Elect Choice®, Aetna Open Access® HMO, Aetna Open Access® Managed Choice®, Open Access Aetna Select^SM, Elect Choice®, HMO, Managed Choice® POS, Open Choice®, Quality Point-of-Service® (QPOS®) benefits plans, Choose and Save^SM, Savings Plus, Aetna Select® benefit plans and all products that may include the Aexcel® networks and include the designation Aexcel or Aexcel Plus®.

Open Choice and Traditional products require precertification for Inpatient Admissions and Residential Treatment, although they may not have precertification requirements for additional Outpatient procedures listed below.

Precertification list 

Precertification is required for the following services, if covered under the member’s benefits plan*:

• Inpatient admissions
• Residential treatment center admissions
• Partial hospitalization programs
• Intensive outpatient programs
• Psychological testing
• Neuropsychological testing
• Outpatient electroconvulsive therapy
• Biofeedback
• Amytal interview
• Psychiatric home care services
• Outpatient detoxification
• Applied Behavior Analysis (ABA)  (effective 4/1/2010)

* Member Plan of Coverage should be reviewed to verify any additional plan precertification requirements.

Precertification exceptions

This policy applies to all Aetna plans with the exception of:

• Behavioral health benefits plans that we administer, but do not manage
• Self-funded plans with plan sponsors who have expressly purchased precertification requirements

There may be plan sponsors whose plans require preauthorization for all outpatient services.  Please ask your patients if they are covered under a plan with this requirement.

*The term precertification means the utilization review process to determine whether the requested service or procedure meets the company’s clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.

**Aexcel is not available with HMO plans. Aexcel designation is only a guide to choosing a physician.  Members should confer with their existing physicians before making a decision.  Designations have the risk of error and should not be the sole basis for selecting a doctor.

***Not all plans are offered in all service areas. Aetna HealthFund PPO, Aetna HealthFund Managed Choice, Aexcel, Choice POS, Choice POS II, Aetna Medicare Plans, Open Access Managed Choice, QPOS, and USAccess benefits plans may include the option for members to elect to go outside the network and receive reduced benefits.