Skip to main content

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)

 

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

 

2021 Colorado Medical/Behavioral Health Prior Authorization Report (PDF)

 

2021 Pharmacy/Behavioral Prior Authorization Report (PDF)

 

2021 Pharmacy Appeals/Behavioral Health Prior Authorization Report (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. 

 

Anti-bias training requirement

 

The Colorado Division of Insurance requires that providers and front office staff who participate in Individual and Small Group ACA plans complete anti-bias, cultural competency or similar training annually to help patients who experience higher rates of health disparities or inequities. 

 

Providers are responsible for coordinating their own training.

 

This training must be completed no later than January 1, 2023. In December, we will ask you to provide the details of the training provided, including:

 

·         Who provided the training

·         The date the training was completed

·         Course duration

·         The number of staff in attendance 

 

Each carrier must report this information annually to the Division of Insurance for their provider network. 

 

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.

Also of interest: