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Precertification
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Concurrent Review
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Retrospective Review
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Electronic PrecertificationYou can request a precert or make a precert inquiry electronically. To get started, contact one of our clearinghouse vendors. |
Physician Advisory BoardWe are committed to working cooperatively with the medical community and building collaborative relationships through our Physician Advisory Board. |
What is precertification?
Precertification is the process of collecting information before inpatient admissions and select ambulatory procedures and services. Precertification applies to:
Procedures and services on the precertification lists may require notification and/or a coverage determination.
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:
The precertification process helps Aetna:
Provider and benefits plan applicability
Precertification applies, as follows, to all benefits plans that include a precertification requirement:
Medicare Advantage members, member authorized 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.
For a list of the specific benefits plans to which precertification applies, see the appropriate precertification list.
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 identification card.
More stringent state requirements may supersede these requirements.
1For precertification, concurrent and retrospective reviews, an individual must satisfy at least one of the following requirements in order to be considered an authorized representative of a member:
1. 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.
2. The individual is authorized by law to provide substituted consent for a member (for example, parent of a minor, legal guardian, foster parent, power of attorney); or,
3. For pre-service, urgent care or concurrent care claims only, the individual is an immediate family member of the member (for example, spouse, parent, child, sibling); or,
4. For pre-service, urgent care or concurrent care claims only, the individual is a primary caregiver of the member; or,
5. 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 (for example, the treating physician).
2For 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.