Prior authorization statistics for commercial insured business
Price estimates
Price estimates can be made in the Aetna member website.
If a service or procedure is not found on the Aetna member website, New Jersey members can obtain an estimated cost for out-of-network services by completing the appropriate Member Request for Estimate Form or by visiting the FAIR Health, Inc.* website. The estimates provided on this site will not take into account whether or not the member’s coinsurance and other plan cost-share limits when the estimate is provided.
Estimate costs of out-of-network services
Aetna member (PDF)
Aetna Voluntary member (PDF)
Boon member (PDF)
Aetna student health member (PDF)
*FAIR Health Marks and the FAIR Heath Logo are trademarks or registered trademarks of FAIR Health, Inc.
If you would prefer a printed copy of this information, or a printed list of providers, contact Member Services at the toll-free number on your ID card.
Learn more about managing your health care costs
Important information about your out-of-network benefits
Refer to this document for Important Information on Out of Network Claims.
It covers some details on voluntary and involuntary uses of out of network providers. The information on voluntary out-of-network benefits only applies if your plan has voluntary out-of-network benefits.
Out-of-network disclosures (PDF)
How we compensate your health care providers
Health care providers are independent practicing professionals that are neither employed nor exclusively contracted with Aetna. Individual physicians and other providers are in the network by either contracting with us directly or by affiliating with a group or organization that contracts with us.
We compensate these health care providers:
- Per individual service or case (fee for service at contracted rates).
- Per hospital day (per diem contracted rates).
- Through capitation (a prepaid amount per member, per month).
- Through Integrated Delivery Systems (IDS), Independent Practice Associations (IPA), Physician Hospital Organizations (PHO), Physician Medical Groups (PMG), behavioral health organizations and similar provider organizations or groups. Aetna pays these organizations, which in turn may reimburse the physician, provider organization or facility directly or indirectly for covered services. In such arrangements, the group or organization has a financial incentive to control the cost of care.
One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal.
Producer Transparency
Disclosure of a Financial Interest in the Sale of Health Insurance Policies (PDF)
Claim reimbursement examples
The claim reimbursement examples (PDF) has examples of average submitted charges and allowances for commonly billed voluntary out-of-network services. Actual charges and costs may vary. Follow the steps on this page to obtain a price estimate for any planned out-of-network covered services.
Out-of-network exceptions
You can ask for an exception to have an out-of-network service treated as a network benefit when:
- a network provider with the needed training or expertise is not available for your condition; or
- a participating provider is not accessible.
You or your provider must get pre-approval (pre-cert) from Aetna for the services to be covered. You or your provider can call the precert number on your identification card to start the process.
Note: Doctors, chiropractors and podiatrists must inform you of certain financial interests.
The laws of the State of New Jersey, at N.J.S.A 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make referrals to other health care providers in which she/he has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care provider or facility when making a referral to that health care provider or facility. If you want more information about this, contact your physician, chiropractor or podiatrist. If you believe that you are not receiving the information to which you are entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at 1-973-504-6200 OR 1-800-242-5846.
Extension of benefits
A subscriber or dependent may be eligible for continued coverage under the Aetna benefits plan if the subscriber's plan would otherwise terminate but the plan includes a provision for continued coverage for total disability and the subscriber or dependent initiates a request for continued coverage by contacting Aetna Member Services.
The individual who is totally disabled must meet the extension eligibility requirements on the date that coverage would otherwise end.
If the request for continued coverage is approved, the continued coverage applies only to the individual who is disabled and not to other family members. In addition, the terms of coverage at the time of the approved extension remain in effect and the continued coverage would be subject to all plan provisions and limitations.
The following forms must be completed and submitted to Aetna Member Services for consideration. The mailing address appears on the forms.
Request for extension of benefits due to total disability (PDF) — This form requires a statement from the treating practitioner(s) supporting the request.
Handicapped child/behavioral health attending physician's statement (PDF) — For behavioral health conditions in children and adults, and medical conditions in dependents age 18 and younger.
Adult medical attending physician's statement (PDF) — For medical conditions in adults.
Present on Admission indicator code
Effective 10/1/2008, Present on Admission (POA) indicator codes will be required for determining appropriate DRG (Diagnosis Related Grouping) assignment and thus pricing. The code is required for both Commercial and Medicare lines of business. A POA code is a code used to indicate if the corresponding diagnosis was present at the time of admission. A POA code is required for all primary and secondary diagnosis codes; however a POA code is not needed for the admitting diagnosis code. Refer to the below for a list of POA indicator codes.
Value in the POA - Field Meaning
- Y - Diagnosis was present at the time of inpatient admission.
- N - Diagnosis was not present at the time of the inpatient admission.
- U - Documentation insufficient to determine if condition was present at the time of inpatient admission.
- W - Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of the inpatient admission.
- 1 or Spaces Unreported/not used - Exempt from POA reporting.
Health insurance carriers must inform subscribers about organ and tissue donation and registration
Health insurance carriers are now required to provide subscribers written informational materials about organ and tissue donation and registration at each contract renewal. These materials must:
- Be developed or approved by a federally designated organ procurement organization; and
- Inform subscribers on how to make an anatomical gift, including information on the registration of a gift in the Donate Life New Jersey registry.
Organ and tissue donation and registration – English (PDF)
Organ and tissue donation and registration – Spanish (PDF)
