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Utilization management

Learn how we determine coverage and find information about important policies and utilization review.

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
  • Level of Care Utilization System for Psychiatric and Addictive Services (LOCUS)
  • Child Adolescent Level of Care Utilization System for Psychiatric and Addictive Services/ Child and Adolescent Service Intensity Instrument (CALOCUS-CASII)

 

Outside vendors

Outside vendors

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

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.