Medicare Aetna Precertification Tool Explained

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Before doctors and health care providers determine the cost of a patient’s health, they must first obtain approval from the health plan that the patient chooses before certain services are provided to the patient in order to qualify for payment coverage. The term to describe this process is called precertification.

With Aetna, you will be able to see if your precertification is required. Of course, it will make it easier for you to determine if a special program actually applies. As an Aetna member, how to check if the precertification is required in Aetna? To know the guide of checking the precertification with Aetna, you can see our post below!

How to Use Precertification Tool in Aetna?

The only one way to check if the precertification is required in Aetna, you just simply use the Precertification tool that can be found at Aetna official page here. In this page, you will find a simple tool  that you can use to see if the precertification is required.

‘Search by CPT code’ is the section that allows you to see if precertification is required. To start checking if the precertification is required, you  can just enter one or more 5-digit CPT codes in the available bar.

After entering the 5-digit CPT code, you need to enter the ‘Submit’ button to continue your search. The following page should bring you the result of precertification whether it is required or not. That’s how to use the precertification tool in Aetna to find out whether precertification is required in your health care or not.

Using a precertification  by tracking the CPT code is very necessary to review your applicable medical records. In this case, the tracking number does not indicate approval. Afterwards, you will be notified as a coverage decision is completely made.

It’s important to note, the Aetna Student Health Precertification List is under revision. If you need help, you can contact Aetna Student Health Customer Service at 1-877-480-4161.

When is the Precertification Required?

Precertification will occur before inpatient admissions and choose ambulatory procedures and services. Precertification will apply to:

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

You definitely can file a precertification by electronic data interchange (EDI) through Aetna’s secure provider website or by phone, using the number of the member’s ID card.

List of Aetna Services Required Precertification

Here’s a list of Aetna’s services that require precertification participating provider precertification list 2022 that we get from official Aetna site in the section of ‘Prescription’ that you can access HERE:

  1. Inpatient confinements (except hospice). For example, surgical and nonsurgical stays, stays in a skilled nursing facility or rehabilitation facility, and maternity and newborn stays that exceed the standard length of stay (LOS).
  2. Ambulance: Precertification required for transportation by fixed-wing aircraft (plane)
  3. Arthroscopic hip surgery to repair impingement syndrome including labral repair
  4. Autologous chondrocyte implantation
  5. Cataract surgery
  6. Chiari malformation decompression surgery
  7. Cochlear device and/or implantation
  8. Coverage at an in-network benefit level for out-of-network providers or facilities unless services are emergent. (Some plans have limited or no out-of network  benefits).
  9. Dental implants
  10. Dialysis visits (When a participating provider initiates a request and dialysis is to be performed at a nonparticipating facility).
  11. Dorsal column (lumbar) neurostimulators: trial or implantation
  12. Electric or motorized wheelchairs and scooters
  13. Endoscopic nasal balloon dilation procedures
  14. Functional endoscopic sinus surgery (FESS)
  15. Gender affirmation surgery
  16. Hyperbaric oxygen therapy (Proprietary)
  17. Infertility services and pre-implantation genetic testing
  18. Lower limb prosthetics, such as microprocessor-controlled lower limb prosthetics
  19. Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider
  20. Orthognathic surgery procedures, osteotomies, bone grafts, and surgical management of the temporomandibular joint
  21. Osseointegrated implant
  22. Osteochondral allograft/knee
  23. Private duty nursing
  24. Proton beam radiotherapy
  25. Reconstructive or other procedures that may be considered cosmetic.
  26. Shoulder Arthroplasty including revision  procedures
  27. Site of Service (For commercial members only, see special programs for additional information)
  28. Spinal procedures, such as: Artificial intervertebral disc surgery (cervical spine), Arthrodesis for spine deformity, Cervical laminoplasty, Cervical, lumbar and thoracic laminectomy and\or laminotomy procedures, Kyphectomy, Laminectomy with rhizotomy, Proprietary, Spinal fusion surgery, Vertebral corpectomy.
  29. Uvulopalatopharyngoplasty, including laser- assisted procedures
  30. Ventricular assist devices
  31. Video electroencephalography (EEG)
  32. Whole exome sequencing

In addition to participating provider precertification lists, Aetna also provides the services that require precertification or authorization. Certainly, the requirement will apply only to services that are covered under the member’s benefits plan, including:

  • Applied behavioral analysis (ABA)
  • Inpatient admissions
  • Partial hospitalization programs (PHPs)
  • Residential treatment center (RTC) admissions
  • Transcranial magnetic stimulation (TMS)

How to request precertification or authorization? Behavioral health services that include treatment or substance use disorders actually require either authorization or precertification. To request it, you can submit an electronic precertification request on Availity.com, as Aetna’s provider website.

Aside from that, you can also select other websites allowing you for precertification request. You can also go to http://aetna.com/provider/vendor to see Aetna vendor list. Last, you can also require electronically about previously submitted requests.

What are the Criteria for Coverage Determination?

Normally, there are a bunch of criterias that will be recognized and used during the coverage determination process. Well, the criteria here include:

  • Aetna Clinical Policy Bulletins (CPBs)
  • National Coverage Determinations (NCDs), Centers for Medicare & Medicaid Services (CMS), Local Coverage Determinations (LCDs) and Medicare Benefit Policy Manual
  • MCG guidelines
  • American Society of Addiction Medicine (ASAM) Criteria; Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, Third Edition
  • Level of Care Assessment Tool (LOCAT)
  • Applied Behavior Analysis (ABA) Guidelines for the Treatment of Autism Spectrum Disorders

The term ‘coverage’ here is either the determination of whether or not the specific service or treatment is a covered benefit pursuant to the terms of the specific member’s benefits plan in which a provider is required to comply with Aetba’s utilization management programs, whether the specific service or treatment is payable under the terms of the provider agreement or not.

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