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Determining level of care and coverage
[Copy] We may evaluate your patient’s care while the person is in the hospital or undergoing outpatient treatment. Our goal is to help make sure the person gets the right level of care at the right time. And at a reasonable cost. A concurrent review also determines if the person’s plan covers the treatment under review.
The concurrent review process includes:
- Collecting information from the care team about the person’s condition and progress
- Determining coverage based on this information
- Informing everyone involved in the patient’s care about the coverage determination
- Identifying a discharge and continuing care plan early in the stay
- Assessing this plan during the stay
- Identifying and referring potential quality of care concerns and patient safety events for additional review
- Identifying people for referral to our covered specialty care programs, such as case management and disease management, behavioral health, the National Medical Execellence Program®, women's health programs such as the Beginning Right® Maternity Program and the infertility program.
Concurrent review may be done by phone, fax or on-site at the facility.
For the purposes of this policy, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.
More stringent state requirements may supersede the requirements of this policy.
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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.