Concurrent review includes utilization management activities that take place during an inpatient level of care or an ongoing outpatient course of treatment (for example, behavioral health partial hospital program [PHP], behavioral health intensive outpatient program [IOP], home health care [HHC] services).
The concurrent review process includes:
Concurrent review may be conducted by phone, fax or, as applicable, on-site at the facility where care is delivered.
More stringent state requirements may supersede the requirements of this policy.
1For the purposes of this policy, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.