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A prior authorization is a request submitted on your behalf by your health care provider for a particular procedure, test, treatment, or prescription. It is sometimes known as precertification or preapproval.
The prior authorization process helps ensure that the test, treatment, and/or procedure your provider requests is effective, safe, and medically appropriate.
The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. All decisions are backed by the latest scientific evidence and our board-certified medical directors.
Step #1: Your health care provider submits a request on your behalf.
Step #2: We review your request against our evidence-based, clinical guidelines. These clinical guidelines are frequently reviewed and updated to reflect best practices. Your health care provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision.
Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. If this is the case, our team of medical directors is willing to speak with your health care provider for next steps.
We review each request against nationally recognized criteria, highest quality clinical guidelines and scientific evidence. Our clinical guidelines are based on:
- Guidelines from nationally recognized health care organizations such as the Centers for Medicare and Medicaid Services (CMS)
- Peer-reviewed, published medical journals
- A review of available studies on a particular topic
- Evidence-based consensus statements
- Expert opinions of health care professionals
We offer a variety of resources to support you through your health care journey, including:
Resources For Living® Program
We’re here with 24/7 support and resources to help you with work/life balance, caregiving, legal services, money matters, and more. It’s confidential and free for you and all your household members.
MinuteClinic® at CVS® services
MinuteClinic at CVS is a convenient retail clinic that you'll find in select CVS Pharmacy® and Target stores. You can take advantage of a wide range of services across a variety of categories, including:
- COVID-19 services: Vaccines and testing (including antibody tests)
- Immunizations: Such as flu shots, MMR and HPV
- Screenings: Including screenings for high cholesterol and diabetes
- Physicals: Camp, sports, and DOT physicals
- Minor illnesses: Like strep, flu-like symptoms or the common cold
- Minor injuries: Such as sprains, strains, bug bites and joint pain
- Women and men’s services: Including birth control and erectile dysfunction
- Pre-travel health: Pre-travel consultations to help prevent you from getting certain illnesses and conditions while traveling
Enjoy an enhanced health care service and shopping experience with CVS HealthHUB in select CVS Pharmacy locations. CVS HealthHUB offers all the same services as MinuteClinic at CVS with some additional benefits.
What’s the difference?
At a MinuteClinic inside a CVS Pharmacy, you may see nurse practitioners (NPs), physician associates (PAs) and pharmacists. But at MinuteClinics located in select CVS HealthHUBs, you can also find other professionals such as licensed therapists who can help you on your path to better health.
We evaluate each case using clinical criteria to ensure each member receives the right care at the right time in their health care journey. In some cases, not enough clinical documentation could result in a denial. Other times, medical necessity criteria might not be met.
If your prior authorization request is denied, the following options are available to you:
- Denial letter guidance. If your prior authorization request is denied, you’ll receive a letter from Aetna. The letter will outline the reason for the denial and why your request didn’t meet medical necessity. You may discuss the letter with your provider as well as alternative care options.
- Request a peer-to-peer review between your provider and a medical director. During this review, your health care provider and a medical director from Aetna will discuss medical necessity guidelines that are relevant to your prior authorization request. Your provider may also wish to share additional clinical information. This discussion can only happen between your health care provider and a medical director at Aetna.
- Request a formal appeal. Your denial letter will outline the steps to make a formal appeal to Aetna about the denial decision. You can also find more information about how to appeal a denied claim and your rights as a member.
We want to make sure you receive the safest, timely, and most medically appropriate treatment. That’s why we partner with your provider to accept requests through convenient options like phone, fax or through our online platform. We stay in touch with providers throughout the prior authorization request. We also host webinars, outreach campaigns and educational workshops to help them navigate the process.
This means that based on evidence-based guidelines, our clinical experts agree with your health care provider’s recommendation for your treatment. If you have questions, you can reach out to your health care provider. Or, call us at the number on your ID card. We’re here to help.
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.