Aetna Medicare Advantage Prior Authorization

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There are several types of care that need to be preapproved by your doctor. Here we are going to inform you of the right care when you need it. Just read the text below to find out more about getting prior authorization for care.

What is Prior Authorization?

Several care will need your doctor to get their approval first. This process is called prior authorization. Or some people called it as preapproval. It means that Aetna Better Health® agrees that the care is necessary for your health. Actually, you never need preapproval for emergencies.

These are several of the common services which need prior authorization or preapproval:

  • Overnight hospital stays
  • Services outside of the Aetna Better Health service area
  • Major surgeries
  • Specialist visits
  • Expensive medications administered by your own provider or at your provider’s office
  • Any service which is considered medically necessary

How to Get Prior Authorization?

By the way, how to get prior authorization? Please follow these steps to get preapproval:

  • Visit page for prescription drugs
  • Then, your primary care physician (PCP) will give Aetna Better Health information about the services which they think you need.
  • After that, an Aetna Better Health of California provider is going to review the information.
  • If that provider does not think the request should be approved, a different Aetna Better Health of California provider is going to review the information.
  • You and your provider are going to get a letter stating whether the service has been approved or denied.
  • They are going to make a decision within 5 business days, or 72 hours for urgent care.
  • If they deny your service, they are going to explain why in the letter.
  • If they deny a service, you or your provider, with your written permission, will be able to submit an appeal.

Form of Aetna Prior Authorization

An Aetna prior authorization form is designated for the medical offices when a certain patient’s insurance is not listed as eligible. This form will ask the medical office for the right to be able to write a prescription to their patient whilst having Aetna cover the cost as stated in the insurance policy. The form should be completed by the medical staff and submitted to Aetna in the proper state jurisdiction.

To write:

  • Start by providing the patient’s Aetna member number, group number, and specify if or not the patient is enrolled in Medicare.
  • After that, provide the employee’s full name, full address, date of birth, company name, and company address. Then, the employee must supply their signature, telephone number, and date the signing.
  • In “Prescription(s) were for”, you have to specify the patient’s full name, sex (m/f), signify who the prescription is for, and provide the patient’s date of birth.
  • In “Prescription(s) were for”, you have to choose yes or no to indicate whether or not the patient’s family members’ expenses are covered by another group health plan. If yes, you have to include the policy holder, policy number, name and address of the insurance company.
  • In “Prescription(s) were for”, you have to specify the patient’s Medicare type. Also, you need to provide the member ID number with another carrier along with the member’s name and birthdate.
  • In “Prescription(s) were for”, you have to indicate the reason for manually filling the request.
  • In “Submission Requirements”, if the prescribing physician’s NPI number is from a foreign country, then you need to specify the physician’s country, currency, and amount.

Referrals and Prior Authorizations

Occasionally, you need a referral or prior authorization before you are able to get care. A referral is a type of preapproval from your primary care doctor to see a specialist. A prior authorization or precertification is when your doctor must get approval from them before they cover an item or service. Prior authorizations are frequently used for things like MRIs or CT scans. Of course, your doctor is in charge of sending them prior authorization requests for medical care.

Need to know that each plan has rules on whether a referral or prior authorization is required. You have to check your plan’s Evidence of Coverage (EOC) to view if or how these rules apply. Warning: If you are viewing an EOC online, simply you are able to press Ctrl + F to search for an item. You will be able to find most rules for referrals or prior authorizations in Chapter 4.

When Does Aetna Require Precertification?

Precertification will occur before inpatient admissions and choose ambulatory procedures and services. The precertification applies to:

  • Procedures and services on the list of Aetna Participating Provider Precertification.
  • Procedures and services on the list of Aetna Behavioral Health Precertification.
  • Procedures and services which require precertification under the terms of a member’s plan
  • Any organization determination that is requested by a Medicare Advantage member, representative or physician for a coverage decision

You are able to submit a precertification by electronic data interchange (EDI), through their secure provider website or by phone, using the number on the member’s ID card.

The Benefits of Precertification

Here are some benefits of Precertification:

  • You and their members are going to know coverage decisions before procedures, services or supplies are provided.
  • They are able to identify the members and get them into specialty programs, such as case management and disease management, the National Medical Excellence Program and behavioral health.

Notification and Coverage Determination

Procedures and services on the precertification lists probably need notification and/or a coverage determination.

  • Notification is a process of data-entry. It does not need judgement or interpretation for benefits coverage.
  • A coverage determination is dependent upon plan documents and a review of clinical information to specify whether clinical guidelines or criteria for coverage are met.

Aetna staff members are trained to decide whether a caller is making an inquiry or requesting a coverage decision or organization determination as part of the intake process.

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