Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy

Precertification is the process of confirming eligibility and collecting information prior to inpatient admissions and selected ambulatory procedures and services listed on:

• The Aetna Participating Provider Precertification List.
• The Aetna Behavioral Health Precertification List.  (1 page)
• A plan sponsor-specific precertification list.

These lists are collectively referred to below as “Precertification List.”
Precertification may include a notification process and/or a coverage¹ determination process.

• Notification is the process of recording a coverage request for services or supplies included on the Precertification List. Notification is only a data-entry process and does not require judgment or interpretation for benefits coverage.


• Coverage determination requires the review of plan documents and clinical information regarding the service or supply to determine whether clinical guidelines/criteria for coverage are met.
• Coverage determinations may be based on plan documents and nationally recognized guidelines/criteria. These include Centers for Medicare & Medicaid Services (CMS) guidelines; Milliman Care Guidelines^®; the American Society of Addiction Medicine Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition – Revised (ASAM-PPC-2R); Aetna Clinical Policy Bulletins (CPBs); and, for mental health admissions, the Aetna Level of Care Assessment Tool (LOCAT^©).

The precertification process facilitates:

• Communication of a coverage decision to the treating practitioner and/or member in advance of the procedure, service or supply.
• Identification of members for pre-service discharge planning.
• Identification and registration of members for covered Aetna Health Connections^SM specialty programs, such as the Case Management, Disease Management, Behavioral Health, National Medical Excellence and Beginning Right^SM Maternity programs. 

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 are required to pursue precertification when required, not members.


• A plan sponsor may require members to obtain precertification for certain services.
• This would apply when this requirement is included in the member’s Certificate of Coverage or Summary Plan Description.
• A participating provider has no obligation for this precertification requirement.

For a list of the specific benefits plans to which precertification applies, see the applicable Precertification List.

• Not all benefits plans are offered in all service areas.


• For plans with out-of-network benefits (for example, QPOS^®, Aetna HealthFund^®, Aetna Golden Choice^™ Plan, Aetna Open Access^® Managed Choice^®, Aetna Choice^® POS II, USAccess^® and Managed Choice POS), the use of a nonpreferred provider may result in reduced benefits.


• Medicare Open (PFFS) plans do not require precertification; however, precertification is performed, if requested, for procedures/services listed on the Aetna Participating Provider Precertification List.

How to submit a precertification request
Precertification requests may be submitted electronically through an electronic data interchange (EDI) or Internet solution, by telephone, or in writing by fax or mail.
More stringent state requirements supersede these requirements.