Request or inquire on a precert using our secure provider website or one of our clearinghouse vendors. Attend a free webinar to learn more.
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.
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 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.
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)