Skip to main content

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.

Drug infusion site of care policy

Learn 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.

Clinical questionnaire for prior authorization requests

We’ve made it easier to request authorizations for selected procedures through the Availity® provider portal.

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.