Precertification

Aetna Utilization Review Policy

Precertification

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

The Aetna National Participating Provider Precertification List.
The Aetna Behavioral Health Precertification List.
A plan sponsor precertification list.

These lists are collectively referred to hereafter as “Precertification List.”
There are two components to precertification: notification and coverage¹ determination.

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, Aetna Clinical Policy Bulletins (CPBs) and, for mental health admissions, the Aetna Level of Care Assessment Tool (LOCAT^®).

The precertification process facilitates communication with the treating practitioner and/or member in advance of the procedure, service or supply; the identification of members for pre-service discharge planning and the identification and registration of members for specialized programs, such as Case Management and Disease Management.

Provider and benefits plan applicability
Precertification applies, as follows, to all benefits plans that include a precertification requirement:

The Aetna National Participating Provider Precertification List and the Aetna Behavioral Health Precertification List apply to participating providers.
A plan sponsor may require members to obtain precertification for certain services.

This is a member requirement and is included in the 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, Managed Choice^® Open Access, Choice POS, USAccess^® and Managed Choice), the use of a nonpreferred provider may result in reduced benefits.

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.

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