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Aetna Utilization Review Policy

Precertification

Precertification is the process of confirming eligibility and collecting information prior to:

There are two components to precertification: notification and coverage determination.

Precertification applies to all products in which the benefit plan includes a 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.

More stringent state requirements supersede these requirements.

1For 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.