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 or on a plan sponsor precertification list (referred to hereafter collectively as "Precertification List").
There are two components to precertification: notification and coverage 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 benefit coverage.
- Coverage determination may require the review of plan documents and clinical information regarding the service or supply to determine whether clinical guidelines/criteria for coverage are met.
- Coverage decisions may be based on plan documents and nationally recognized guidelines/criteria, Aetna Clinical Policy Bulletins (CPBs) and/or, for mental health admissions, the Aetna Level of Care Assessment Tool (LOCAT).
Precertification applies to all products in which the benefit plan includes a precertification requirement.
- The Aetna National Participating Provider Precertification List applies to participating providers.
- A plan sponsor may require members to obtain precertification for 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.
The precertification process permits eligibility verification/confirmation, determination of coverage1 and communication with the physician and/or member in advance of the procedure, service or supply. Precertification also allows Aetna to identify members for pre-service discharge planning and to identify and register members for specialized programs such as Case Management and Disease Management.
Precertification requests may be submitted electronically through an Electronic Data Interchange (EDI) or Internet solution, telephonically or in writing by fax or mail. Precertification applies to all of the benefits plans listed on the Aetna National Participating Provider Precertification List.
- Not all benefits plans are offered in all service areas.
- For plans with out-of-network benefits (e.g., QPOS®, Aetna HealthFund®, Aetna Golden Choice™ Plan, Managed Choice® Open Access, Choice POS, USAccess® and Managed Choice®), when a member elects to utilize non-preferred providers, the Aetna National Participating Provider Precertification List does not apply and members may receive reduced benefits.
More stringent state requirements supersede these requirements.
