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New preapproval requirements for members in Nebraska, Colorado, Michigan and Wisconsin


Our Enhanced Clinical Review Program with eviCore healthcare requires authorization for certain procedures. This affects members in our Medicare Advantage HMO/PPO Aetna® products. These requirements are effective for: 

  • Nebraska as of February 1, 2019  

  • Colorado as of April 1, 2019 

  • Michigan as of July 1, 2019 

  • Wisconsin as of July 1, 2019 

 

Services that need preapproval 

  • High-tech outpatient diagnostic imaging procedures such as MRI/MRA, nuclear cardiology, and PET scan and CT scan, including CTA  

  • Non-emergent outpatient stress echocardiography 

  • Non-emergent outpatient diagnostic left and right heart catheterization 

  • Insertion, removal and upgrade of elective implantable cardioverter defibrillator, cardiac resynchronization therapy defibrillator and implantable pacemaker 

  • Polysomnography (attended sleep studies) 

  • Interventional pain management 

  • Musculoskeletal large joint (hip and knee) arthroplasty procedures 

 

Services that do not need preapproval 

  • Inpatient radiology  

  • Emergency room radiology  

  • Outpatient radiology other than those services listed above 

 

For a complete list of procedures requiring an authorization, visit eviCore healthcare at eviCore.com

The requested services are reviewed in accordance with applicable Medicare National Coverage Determinations and Local Coverage Determinations, nationally recognized clinical and billing guidelines of the American College of Radiology (ACR), guidelines from other recognized medical societies, any state regulations or mandates, and Aetna’s Clinical Policy Bulletins (CPBs).  

Before services are performed, eviCore healthcare’s board-certified physicians will review authorization requests for medical necessity.  

To review our CPBs, visit us at aetna.com and look under the Helpful Links section. 

 

How to get preapproval

 

Urgent requests 

If members need services in less than 48 hours due to medically urgent conditions, call eviCore healthcare for fast review. Tell the representative the request is for medically urgent care. 

 

What you should know 

  • We recommend that ordering physicians get authorizations and share the approval numbers with the facility performing the procedure when it is scheduled.  

  • eviCore healthcare will fax its approval decision to the ordering physicians and requested facilities. 

  • Approvals have authorization numbers and one or more CPT codes specific to the approved services.  

  • If the service you ask for is different from what eviCore healthcare approves, the facility must contact eviCore healthcare for review and approval before submitting claims. 

  • If you perform services without approval, we may deny payment.  

  • We determine coverage in accordance with the policy’s terms and conditions and with our policies and procedures. 

 

We’re here to help 

If you have questions, call eviCore healthcare at 1-888-693-3211. Or you can call Provider Services at: 

  • 1-800-624-0756 (TTY: 711) for HMO and Medicare Advantage benefits plans 

  • 1-888-MD-AETNA (1-888-632-3862) (TTY: 711) for all other plans