Precertification

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 Aetna Participating Provider Precertification List and the Aetna Behavioral Health precertification list
• Any organizational determination made by a Medicare Advantage member or on behalf of the member by his/her authorized representative¹ or physician for an advance coverage² 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)
• The Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and the 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 and/or members/member authorized representatives before procedures, services or supplies are provided
• Identify and register members for covered specialty programs, including Aetna Health Connections^SM case management and disease management, behavioral health, National Medical Excellence 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 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.

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