Confirm patient eligibility and collect important information
Precertification occurs before inpatient admissions and select ambulatory procedures and services. Precertification applies to:
You can submit a precertification by electronic data interchange (EDI), through our secure provider website or by phone, using the number on the member’s ID card.
Procedures and services on the precertification lists may require notification and/or a coverage determination.
Verbal or written requests for information about benefits or services covered under the terms of a specific member’s plan for services not on the precertification lists are not part of the precertification process. Aetna staff members are trained to determine whether a caller is making an inquiry or requesting a coverage decision/organization determination as part of the intake process.
Nationally recognized guidelines or criteria that may be used during the coverage determination process include:
For these purposes, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is contractually required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.
More stringent state requirements may supersede our precertification requirements.
*The Centers for Medicaid and Medicare Services (CMS) defines an appointed representative (“representative”) as an individual appointed by an enrollee or other party, or authorized under State or other applicable law, to act on behalf of an enrollee or other party involved in the grievance or appeal. Unless otherwise stated, the representative will have all of the rights and responsibilities of an enrollee or party in obtaining an organization determination, filing a grievance, or in dealing with any of the levels of the grievance or appeals process, subject to the applicable rules described in 42 CFR 422 Subpart M. To meet the CMS definition of appointed representative, the member and the member’s appointed representative must both sign and date a representative form.