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Insurance regulations by state

Guidelines, regulations and forms

Find your state specific-information

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Colorado Regulation 425 Credentialing of physician by carriers (PDF)

 

Colorado Medical/Behavioral Health Prior Authorization Report 2020 (PDF)

 

Transparency in our pharmacy prior authorization process, annual approval and denial utilization review results (PDF)

 

CO provider demographic survey

 

The Colorado (CO) Division of Insurance has asked that we survey our providers and front office staff.  This survey is voluntary and confidential.

 

To offer a culturally competent network, the CO Division of Insurance requires carriers to survey their members and providers, including front office staff (with direct patient contact), who participate in individual and small group ACA (Affordable Care Act) plans.

 

We’ll use this information to improve racial health equity and reduce health disparities for those who experience higher rates of health disparities and inequities. It also helps give us information about the diversity of providers in our network. We’ll send an aggregate report to the CO Division of Insurance annually.

 

Take part in the survey

 

 Responses are confidential.  Each provider or front office staff who wants to participate should complete a separate survey.

 

If you have questions, just call us at 1-888-632-3862 (TTY: 711).

Aetna is required to comply with various federal and state behavioral health coverage requirements including but not limited to Affordable Care Act’s Essential Health Benefits requirements, the Mental Health Addition Equity Act, and Florida Statutes § 627.668 ST § 627.669. If you have any questions about your behavioral health coverage provided under these laws please contact us at 1-800-424-4047 (TTY: 711).

 

Additionally, you can reach out to the Florida Division of Consumer Services with questions at 1-877-MY-FL-CFO (1-877-693-5236) or by visiting their website.

 

Consumer complaints can be filed directly with the Florida Division of Consumer Services at their website.

 

Provider training – Dual-eligible special needs plans model of care (D-SNP MOC) (PDF)

To download the MDHHS-573 Nonopioid Directive form, visit the Michigan opioid resources page and look under “Additional Resources.”

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 follows:

 

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.

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Health benefits and health insurance plans contain exclusions and limitations.

Information is not a substitute for diagnosis or treatment by a physician or other health care professional.