Determining health care coverage

Utilization management: Guidelines for determining coverage

 


First, our staff collects information about a member's clinical condition.
 
Then, our staff uses evidence-based clinical guidelines from nationally recognized authorities  to guide utilization management decisions involving precertification, concurrent review, and retrospective review.

Aetna staff use the following criteria as guides in making coverage determinations as applicable:

  • Milliman Care Guidelines® for medical and surgical care.
  • Aetna Clinical Policy Bulletins (CPBs), which are based on peer-reviewed published medical literature.
  • Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations and Local Coverage Determinations.
  • Aetna Level of Care Assessment Tool® (LOCAT) for behavioral health care.
  • 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 (TCADA) regulations (used in place of ASAM for Texas members).

Vendors used 
In some states, Aetna delegates utilization review of certain services including radiology and physical/occupational therapy, to outside vendors. Refer to the following vendor websites for a description or copy of the applicable clinical criteria:

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