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Insurance regulations by state
Guidelines, regulations and forms
Find your state specific-information
It’s easy to find what you need here.
Colorado Regulation 425 Credentialing of Physician By Carriers (PDF)
Colorado medical/behavioral health prior authorization report - 2023 (PDF)
Language services
Aetna provides free aids and services to people with disabilities and free language services to people whose primary language is not English. This includes language interpreters and plan details written in other languages. If a patient needs these services, contact the number on the patient’s ID card.
Pharmacy prior authorization statistics for commercial insured business
Colorado pharmacy prior authorization statistics – 2023 (XLSX)
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). You can also visit their website to learn how to contact consumer services.
You can also get help to file consumer complaints with the Florida Division of Consumer Services on their website.
Provider training – Dual-eligible special needs plans model of care (D-SNP MOC) (PDF)
Pharmacy prior authorization statistics for commercial insured business
Georgia pharmacy prior authorization report - 2021 (PDF)
Georgia pharmacy prior authorization statistics – 2022 (XLSX)
Georgia pharmacy prior authorization statistics – 2023 (XLSX)
Aetna® is required to comply with Illinois state law, which allows external stakeholders to request training on behavioral health medical necessity criteria. If you’d like to request this training, send an email to our team.
Prior authorization statistics for commercial insured business
Illinois pharmacy prior authorization statistics – 2023 (XLSX)
Illinois Aetna prior authorization statistics – 2023 (PDF)
Illinois specialty pharmacy prior authorization statistics – 2022 (PDF)
Illinois eviCore prior authorization statistics – 2022 (PDF)
Prior authorization statistics for commercial fully insured business
To download the MDHHS-573 Nonopioid Directive form, visit the Michigan opioid resources page and look under “Additional Resources.”
Prior authorization statistics for commercial insured business
Minnesota prior authorization statistics – 2023 (PDF)
Minnesota specialty pharmacy medical prior authorization statistics – 2022 (PDF)
Minnesota pharmacy prior authorization statistics (ALIC) – 2023 (XLSX)
Minnesota pharmacy prior authorization statistics (ALIC) – 2022 (XLSX)
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.
Present on admission indicator code (PDF)
Continuation of benefits due to total disability form (PDF)
Nonparticipating facility itemized bill review (PDF)
Provider appeal procedure (PDF)
New claims review process for observation room charges (PDF)
New Jersey pharmacy prior authorization statistics (ALIC & AHI) – 2024 (XLSX)
Texas telemedicine and telehealth services
Pharmacy prior authorization statistics for commercial insured business
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.