Precertification

Policy Statements:
Precertification is the process of collecting information before inpatient admissions and select ambulatory procedures and services. Precertification applies to:

• Procedures and services on the Aetna Participating Provider Precertification List and the Aetna Behavioral Health precertification list 
• Any organization determination made by a Medicare Advantage member or made on behalf of the member by his/her appointed representative (“representative”)^1,2, or physician for an advance coverage³ decision
• Procedures and services requiring precertification under the terms of a member’s plan 
  

Procedures and services on the precertification lists may require notification and/or a coverage determination.

• Notification is a data-entry process that does not require judgment or interpretation for benefits coverage.
• A coverage determination is based upon plan documents and, when applicable, a review of clinical information to determine whether clinical guidelines/criteria for coverage are met.
  

Note: Benefits and coverage inquiries that are defined as verbal or written requests for information about benefits or services covered under the terms of a specific member’s plan for services not on the precertification lists are not part of the precertification process. Aetna staff is trained to determine whether the caller is making an inquiry or requesting a coverage decision/organization determination as part of the intake process.

• Nationally recognized guidelines or criteria that may be used during the coverage determination process include:
  • Aetna Clinical Policy Bulletins (CPBs)
  • Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and Medicare Benefit Policy Manual
  • Milliman Care Guidelines^® (MCGs)
  • The American Society of Addiction Medicine Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition – Revised (ASAM-PPC-2R)
  • The Aetna Level of Care Assessment Tool (LOCAT^©) for mental health admissions
  •  Applied Behavioral Analysis (ABA) guidelines for the treatment of autism spectrum disorders

The precertification process helps Aetna:

• Communicate coverage decisions to treating practitioners, members and/or member authorized representatives⁴ /appointed representatives before procedures, services or supplies are provided
• Identify and register members for covered specialty programs, including Aetna Health ConnectionsSM case management and disease management, behavioral health, National Medical Excellence Program^®, and women’s health programs, such as the Beginning Right^® Maternity Program

Provider and benefits plan applicability

Precertification applies, as follows, to all benefits plans that include a precertification requirement:

• The Aetna Participating Provider Precertification List and the Aetna Behavioral Health precertification list apply to participating providers. This means that participating providers, not members, are required to pursue precertification when it is required.
• A member’s plan may require the member to obtain precertification for certain procedures or services. This requirement is included in the member’s Certificate of Coverage or Summary Plan Description. A participating provider has no obligation for this requirement.

Medicare Advantage members, member appointed representatives and providers on behalf of Medicare Advantage members may request a pre-service coverage determination for any procedure/service that the member believes is covered or should be furnished, arranged for or reimbursed by Aetna.

Refer to the appropriate precertification list for a list of the specific benefits plans to which precertification applies.

• Not all benefits plans are offered in all service areas.
• The use of a nonpreferred provider for plans with out-of-network benefits may result in reduced benefits.
  • Plans with out-of-network benefits include: QPOS^®, Aetna HealthFund®, Aetna MedicareSM Plan (PPO), Aetna Open Access^® Managed Choice^®, Aetna Choice^® POS II, Aetna Health Network OptionSM and Managed Choice POS.
    

How to submit a precertification request
Submit precertification requests prior to rendering services through an electronic data interchange (EDI), through our secure provider website or by phone using the telephone number on the member ID card.

More stringent state requirements may supersede these requirements.

¹CMS defines an appointed representative (“representative”) as an individual appointed by an enrollee or other party, or authorized under State or other applicable law, to act on behalf of an enrollee or other party involved in the grievance or appeal. Unless otherwise stated, the representative will have all of the rights and responsibilities of an enrollee or party in obtaining an organization determination, filing a grievance, or in dealing with any of the levels of the grievance or appeals process, subject to the applicable rules described in 42 CFR 422 Subpart M.
²The member and the member’s appointed representative must both sign and date a representative form to meet the CMS definition of an appointed representative.
³For these purposes, "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.
⁴An individual must satisfy at least one of the following requirements to be considered an authorized representative of a member for precertification, concurrent and retrospective reviews for members enrolled in commercial plans:
-The member has given express written or verbal consent for the individual to represent the member's interests.
-A member can appoint an attorney to represent them.
-The individual is authorized by law to provide substituted consent for a member (e.g.-parent of a minor, legal guardian, foster parent, power of attorney); or
-For pre-service, urgent care or concurrent claims only, the individual is an immediate family member of the member (e.g.- spouse, parent, child, sibling); or For pre-service, urgent care or concurrent care claims only, the individual is a primary caregiver of the member; or
-For pre-service, urgent care or urgent concurrent care claims only, the individual is a health care professional with knowledge of the member's medical condition (e.g. - the treating physician)