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Insurance Regulations by State

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Arizona

California

Colorado

Connecticut

Florida

Massachusetts

Missouri

Precertification: Sometimes we will pay for care only if we have given an approval before a member receives care. The Aetna PCP or network provider is responsible for obtaining this approval for covered in-network services. 

You can find Aetna’s precertification list on our Provider website. Alternatively, you can call Member Services to find the services requiring prior authorizations. We cover medically necessary treatment, procedures, therapies and diagnostic ambulatory and inpatient services. We may require submission of clinical information to confirm medical necessity of the requested service, treatment, procedure, diagnostic service, therapy, ambulatory or inpatient service. If the requested information is not received, an administrative denial for lack of clinical information will be made. This will apply in cases where no information is received or if some clinical information is submitted but is inadequate to approve a request for authorization.

Check our precertification lists

Administrative denials for lack of clinical information

If a request for authorization is not certified due to lack of clinical information required to make a medical necessity determination and no appeal has been submitted, we will review the request with additional information as follow:

Precertification Requests:

  • When received within fourteen (14) calendar days of the letter of noncertification; and peer to peer review has not been completed for services that have not yet begun.
    • Aetna will review the additional information with the original request and make a determination based on all information received at that time.
  • When received within fourteen (14) calendar days of the letter of noncertification and peer to peer review has been completed.
    • Aetna will review the additional information along with the original submission as a new precertification request.
  • When received more than 14 days from the date of the denial letter for services that have not yet started and the missing information is received within six (6) months of the date of the denial letter.
    • Aetna will review the additional information along with the original submission as a new precertification request.

Concurrent Review Requests:

  • While the member is receiving ongoing concurrent inpatient or ambulatory services, or within five (5) days of termination of these services.
    • Aetna will review the additional information along with the original submission and render a determination.
  • After the member has been discharged from an acute inpatient event and an adverse determination was issued due to lack of clinical information to support medical necessity, and clinical information is received within five (5) business days of hospital discharge but prior to peer-to-peer review or appeal request.
    • Aetna will review the additional information along with the original submission and render a determination.

Learn more about Concurrent Review

Aetna will review the request and render a determination within Missouri statutory time frames.

Montana

New Jersey

New York

Ohio

Oregon

Pennsylvania

Rhode Island

Texas

Washington

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