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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.

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.