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Utilization Management

How we determine coverage

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Guidelines for coverage determination

Coverage determination is based on guidelines or criteria that include:

  • Aetna’s Clinical Policy Bulletins
  • Centers for Medicare & Medicaid Services National Coverage Determinations, Local Coverage Determinations And Medicare Benefit Policy Manual
  • MCG™ guidelines
  • American Society of Addiction Medicine (ASAM) Criteria; Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition
  • Applied Behavioral Analysis (ABA) Medical Necessity Guidelines© for the Treatment of Autism Spectrum Disorders
  • Level of Care Assessment Tool (LOCAT)

See our Clinical Policy Bulletins
Learn more about ABA, ASAM and LOCAT
Medicare Notice of Coverage Determinations

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Outside Vendors

In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors.

CareCore National
MedSolutions
OrthoNet

Concurrent review

Sometimes utilization management takes place during inpatient care or outpatient treatment.

Learn more about concurrent review

Retrospective review

In a retrospective review, coverage is determined after treatment has occurred.

Learn more about retrospective review

Note: More stringent state requirements may supersede the requirements of this policy.

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