Aetna Utilization Review Policy

Concurrent Review

Concurrent review encompasses those aspects of Patient Management that take place as contemporaneously as feasible during the provision of services at an inpatient level of care or during an ongoing outpatient course of treatment.

Provider¹ requests for extension of coverage² for a course of clinically urgent inpatient or outpatient treatment received prior to the expiration of the current certified number of days/visits/treatments are handled expeditiously as an urgent concurrent review request.
Provider requests for routine extension of an ongoing outpatient course of treatment are handled as a new precertification request.

Concurrent review may be conducted telephonically or on-site at the facility where care is delivered. The concurrent review process includes:

Obtaining necessary information from appropriate facility staff, practitioners and providers regarding the clinical status, progress and care being provided to members;
Assessing the clinical condition of members and the ongoing provision of medical services and treatments to determine benefit coverage;
Notifying practitioners and providers of coverage determinations in the appropriate manner and within the appropriate time frame;
Identifying continuing care needs early in the inpatient stay to facilitate discharge to the appropriate setting; and,
Identifying members for referral to covered specialty programs such as Case Management, Disease Management, Behavioral Health, National Medical Excellence and Women's Health Programs including the Moms-to-Babies Maternity Management Program^®.

Discharge planning is an integral part of inpatient concurrent review. Recognizing and planning for discharge needs begins at the time of notification and continues throughout the hospital stay.

More stringent state requirements supersede this policy.

¹The term "provider" as defined in the Patient Management Program Description and Patient Management policy/procedure is used collectively to mean a practitioner/professional who provides health care services, and is usually required to be licensed as defined by applicable law or regulation, and/or an organizational provider, an institutional provider and/or supplier of healthcare services, including behavioral health care organizations. Organizational providers include, but are not limited to: hospitals, nursing homes; skilled nursing facilities (SNF), home care agencies, free standing surgical centers (including free standing abortion centers and birthing centers). Behavioral health organizations include, but are not limited to: mental health and chemical dependency hospitals, residential treatment facilities, Partial Hospital Programs, Intensive Outpatient Programs and clinics. Behavioral Health organizations can be free-standing or hospital-based. Additionally, in networks where the Medicare individual and/or group products are offered, the organizational providers include: laboratories, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech pathology providers, and providers of end-stage renal disease services.
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 benefit plan, or (ii) where a provider is required to comply with Aetna's patient management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.