Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.
Insurance regulations by state
State-specific guidelines, regulations and forms for providers.
Looking for prior authorization statistics?
Find your state specific-information
It’s easy to find what you need here. For the latest state-specific information, visit OfficeLink Updates and sign up to get future issues and more news for providers.
-
-
-
Policy changes
For important information that may affect your payment, compensation or administrative procedures, refer to the “Important policy information” section of the quarterly OfficeLink Updates newsletter.
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.
Notice Regarding the use of Artificial Intelligence (AI) in Utilization Management (UM):
Aetna may use AI to assist in the processing of claims. AI may be used to auto-approve claims that meet required criteria and to improve client services. Aetna never uses AI to deny care for medical reasons. Adverse decisions based on medical necessity are only made by licensed healthcare professionals.
-
-
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)
-
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.
-
Contracting team: contact information
Thanks for reaching out to Aetna®.
For contract negotiation requests, send an email to the Maine provider contracting team with your name and email address.
Pain management access plan
Pain management access plan (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.
-
-
Notice Regarding the use of Artificial Intelligence (AI) in Utilization Management (UM):
Aetna may use AI to assist in the processing of claims. AI may be used to auto-approve claims that meet required criteria and to improve client services. Aetna never uses AI to deny care for medical reasons. Adverse decisions based on medical necessity are only made by licensed healthcare professionals.
-
-
- Present on admission indicator code (PDF)
- Continuation of benefits due to total disability form (PDF)
- Handicapped child attending physician statement – for behavioral health conditions of all ages and medical conditions for dependents age 18 and younger (PDF)
- Adult medical attending physician statement – for medical conditions for subscriber and dependent s over the age of 18 (PDF)
- Nonparticipating facility itemized bill review (PDF)
- Provider appeal procedure (PDF)
- New claims review process for observation room charges (PDF)
-
-
-
-
-
-
-
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).
Information is not a substitute for diagnosis or treatment by a physician or other health care professional.
Health benefits and health insurance plans contain exclusions and limitations.