When we require precertification
Precertification occurs before inpatient admissions and select ambulatory procedures and services. Precertification applies to:
- Procedures and services on the Aetna Participating Provider Precertification List
- Procedures and services on the Aetna Behavioral Health Precertification List
- Procedures and services that require precertification under the terms of a member’s plan
- Any organization determination made by a Medicare Advantage member, appointed representative* or physician for a coverage decision
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.
The benefits of
precertification
- You and our members (and their appointed representatives) will know coverage decisions before procedures, services or supplies are provided.
- We can identify members and get them into specialty programs, such as case management and disease management, behavioral health, the National Medical Excellence Program®, and women's health programs, such as the Beginning Right® Maternity Program and the infertility program.
Notification and coverage determination
Procedures and services on the precertification lists may require notification and/or a coverage determination.
- Notification is a data-entry process that does not require judgment or interpretation for benefits coverage.
- A coverage determination is based upon plan documents and (when applicable) a review of clinical information to determine whether clinical guidelines/criteria for coverage are met.
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.
Criteria for coverage determination
Nationally recognized guidelines or criteria that may be used during the coverage determination process include:
- Aetna Clinical Policy Bulletins (CPBs)
- Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and Medicare Benefit Policy Manual
- MCGTM guidelines
- American Society of Addiction Medicine (ASAM) Criteria; Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition
- Level of Care Assessment Tool (LOCAT)
- Applied Behavior Analysis (ABA) Guidelines for the Treatment of Autism Spectrum Disorders
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.
