Precertification: How and when?
To get precertification/authorization for mental health, behavioral health or substance abuse services:
Aetna Choice POS®, Aetna Choice® POS II, Aetna MedicareSM Plan (PPO), Aetna MedicareSM Plan (HMO), all Aetna HealthFund® products, Aetna Health Network OnlySM, Aetna Health Network OptionSM, Aetna Open Access® Elect Choice®, Aetna Open Access® HMO, Aetna Open Access® Managed Choice®, Open Access Aetna SelectSM, Elect Choice®, HMO, Managed Choice® POS, Open Choice®, Quality Point-of-Service® (QPOS®) benefits plans, Choose and SaveSM, 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 is required for the following services, if covered under the member’s benefits plan*:
* Member Plan of Coverage should be reviewed to verify any additional plan precertification requirements.
This policy applies to all Aetna plans with the exception of:
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.