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    • Utilization management

    Learn how we determine coverage.

    Guidelines for coverage determination

    Guidelines for coverage determination

    Coverage determination is based on guidelines or criteria that include:

     

    • Aetna® 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 Guide

     

    Outside vendors

    Outside vendors

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

    Drug infusion site of care policy

    The Aetna site of care policy provides the criteria we use to determine the medical necessity of hospital outpatient infusion.

    Concurrent review

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

    Retrospective review

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

    Outpatient surgery site of service policy

    Using cost-effective sites of service for certain outpatient surgical procedures can help members save.

    Radiology imaging site of care policy

    Imaging procedures will be reviewed for medical necessity before being approved in an outpatient hospital setting.

    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).

    Health benefits and health insurance plans contain exclusions and limitations.