Prior Authorization Process & Guidelines

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<li class="megamenumobile__tertiary--item"> <a class="megamenumobile__tertiary--link" href="/individuals-families/member-rights-resources.html" data-linklocation="Navigation" data-linktype="Regular" data-modal="Please Select">Health insurance rights and resources </a> </li> <li class="megamenumobile__tertiary--item"> <a class="megamenumobile__tertiary--link" href="https://www.aetna.com/about-us/contact-aetna.html#tab_content_section_responsivegrid_202619046_responsivegrid_tabs_link_tabs_1" data-linklocation="Navigation" data-linktype="Regular" data-modal="Please Select">Contact us </a> </li> <li class="megamenumobile__tertiary--item"> <a class="megamenumobile__tertiary--link" href="/faqs-health-insurance.html" data-linklocation="Navigation" data-linktype="Regular" data-modal="Please Select">Frequently asked questions </a> </li> <li class="megamenumobile__tertiary--item"> <a class="megamenumobile__tertiary--link" href="/individuals-families/prior-authorization-guidelines.html" data-linklocation="Navigation" data-linktype="Regular" data-modal="Please Select">Prior authorization guidelines </a> </li> </ul> </nav> </div> </li> <li class="megamenumobile__secondary--item"> </li> </ul> </nav> </div> </section> <section class="megamenumobile__panel--tertiary" id="idMegamenumobile__panel--tertiary"> </section> </div> </div> </div> </div> </div> <main> <div class="content_section" id="content__main"> <div class="pageherobanner"> <div class="hero_banner_ps_wrapper hero_banner_secondary "> <div class="hb_image "> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/redesign/hero/AdobeStock_183240457_T6_A7d7dd_1800x420.jpg" alt width="1800" height="420"/> </div> <div class="hb_content"> <div class="container"> <div class="row"> <div class="col-sm-12 col-md-11 col-lg-5 hb_content--wrapper"> <div class="hb_white_box "> <h1 class="hb_white_box_title page__title__hero">How prior authorization protects you</h1> <div class="hb_white_box_subcopy rte-component-wraper mb-0"><p>We take steps to help ensure your treatment is safe, effective and medically right for you. Learn how this review process works and how it helps you.</p> </div>    <div> </div> </div> </div> </div> </div> </div> </div> </div> <div class="textwithmedia"><div class="textmedia " data-cmp-is-async="textwithmedia/one" data-content-well="yes" data-disablereadmore="true"> <div class="container textmedia__componentwrapper textmedia--one component--right textmedia--one--small"> <div class="row"> <div class="col-md-6 col-lg-6 mediawrapper--right"> <div class="textmedia__wrapper"> <div class="textmedia__wrapper--inner"> <div class="textmedia__text textmedia__text--top body__copy"><div class="textdescription text"><div class="rte-component-wraper component--default "> <h2><span class="title__block">What is prior authorization?</span></h2> <p><span class="title--secondary">An extra check to help ensure the right treatment</span></p> <p> </p> <p>Some tests, procedures and medications need approval to be covered. Most times, this is for treatment that’s high cost or complex. Your doctor can send us a request to get that approval. This is called prior authorization. It’s also known as “preapproval” or “precertification.” The Aetna® clinical team will review your doctor’s request. They make sure the treatment is based on the best available clinical research so it’s right for you. </p> <p> </p> <p>This extra check helps connect you to the right treatment. This can help you achieve better health sooner. That might mean a full recovery or being able to better manage a condition.</p> <p> </p> <h3><strong>Here’s an example</strong></h3> <p>You just started having lower back pain. Your doctor suggests an MRI to look into the problem. MRIs for short-term lower back pain can lead to an incorrect diagnosis. This can outweigh the benefits. So, your doctor would need to send us a prior authorization request. Our clinical team will review if the MRI is medically necessary or if other treatment options may be better. </p> </div> </div> </div> </div> <div> </div> </div> </div> <div class="col-md-4 col-lg-4 mediawrapper__small__xsmall mediawrapper--left"> <div class="mediacontainer__slot1 "> <div data-src="/content/dam/aetna/asset-libraries/photos/AdobeStock_419268379_696x928.jpg" class="media__one__image media--hide"></div> <div class="media__one media__image--vertical" data-slot1-image-loaded="false"> <div class="media__content media__image--animate"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/photos/AdobeStock_419268379_696x928.jpg" alt width="696" height="928"/> </div> </div> </div> </div> </div> </div> </div> </div> <div class="responsivegrid"> <div> <div class="container "> <div class="row"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 aem-Grid--md--12 aem-Grid--xs--12 "> <div class="text aem-GridColumn--md--10 aem-GridColumn--default--none aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--default--7 aem-GridColumn--offset--md--1 aem-GridColumn--xs--none aem-GridColumn--xs--12 aem-GridColumn--offset--default--1 aem-GridColumn--md--none"><div class="rte-component-wraper component--default "> <h2><span class="title__block"><span class="title--secondary">How prior authorization works</span></span></h2> <p><span class="title__block">Helping you through every step</span></p> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-extra-small "> </span> </div> <div class="tabs aem-GridColumn--default--none aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--xs--none aem-GridColumn--offset--md--0 aem-GridColumn--default--12 aem-GridColumn--offset--default--0 aem-GridColumn--xs--12 aem-GridColumn--md--none aem-GridColumn--md--12"><div class="tabsComponent component--fullwidth " data-cmp-is-async="tabs" data-content-well="yes"> <div class="tabs__container"> <button class="tab__item tab__item--active" role="tab" id="content_section_responsivegrid_1141134099_responsivegrid_tabs_link_tabs_1" aria-selected="true" tabindex="0" aria-controls="1518531389_panel_1"> <span class="link__tab">What happens if I need prior authorization?</span> </button> <button class="tab__item " role="tab" id="content_section_responsivegrid_1141134099_responsivegrid_tabs_link_tabs_2" aria-selected="false" tabindex="-1" aria-controls="1518531389_panel_2"> <span class="link__tab">My request is in. What happens now?</span> </button> <button class="tab__item " role="tab" id="content_section_responsivegrid_1141134099_responsivegrid_tabs_link_tabs_3" aria-selected="false" tabindex="-1" aria-controls="1518531389_panel_3"> <span class="link__tab">A decision is ready. What’s next?</span> </button> </div> <div class="content__section container"> <section class="content tab__panel tab__panel--dropShadow tab__panel--active"> <div class="title--secondary tab__panel--mobile-btn" role="heading" aria-level="3" aria-controls="1518531389_panel_1"> <button type="button" aria-expanded="true">What happens if I need prior authorization?</button> </div> <div id="1518531389_panel_1" role="tabpanel" aria-labelledby="content_section_responsivegrid_1141134099_responsivegrid_tabs_link_tabs_1" class="content__component" tabindex="0"> <div class="responsive-row"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="textwithmedia aem-GridColumn aem-GridColumn--default--12"><div class="textmedia " data-cmp-is-async="textwithmedia/one" data-content-well="yes" data-disablereadmore="true"> <div class="container textmedia__componentwrapper textmedia--one component--left textmedia--one--small"> <div class="row"> <div class="col-12 d-md-none"> <h4 class="title__block title--mobile">First, your doctor gets the process started</h4> </div> <div class="col-md-4 col-lg-4 mediawrapper__small__xsmall mediawrapper--left"> <div class="mediacontainer__slot1 "> <div data-src="/content/dam/aetna/asset-libraries/photos/AdobeStock_288766040_696x522.jpg" class="media__one__image media--hide"></div> <div class="media__one media__image--horizontal" data-slot1-image-loaded="false"> <div class="media__content media__image--animate"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/photos/AdobeStock_288766040_696x522.jpg" alt width="696" height="522"/> </div> </div> </div> </div> <div class="col-md-6 col-lg-6 mediawrapper--right"> <div class="textmedia__wrapper"> <h4 class="d-none d-md-block title__block">First, your doctor gets the process started</h4> <div class="textmedia__wrapper--inner"> <div class="textmedia__text textmedia__text--top body__copy"><div class="textdescription text"><div class="rte-component-wraper component--default "> <p>When you visit your doctor, they help you get the prior authorization you need. We stay in touch throughout the process. And you get a timely decision.</p> <p> </p> <h5><strong><span class="title--secondary">My doctor recommended this treatment. Why does it need review?</span></strong></h5> <p>Not everything requires this extra check. Some treatments, though, may require this review to help ensure they’re medically necessary, effective and safe. This helps you get the highest quality care.</p> <p> </p> <h5><strong><span class="title--secondary">What if I need prior authorization for a medication?</span></strong></h5> <p>The cost of medicine is rising. So, it’s important to make sure a drug is right for you. This prior authorization is sometimes called “step therapy.”</p> <p> </p> <p>Here’s an example. Your doctor wants to prescribe you an expensive medicine. Our clinical team may find a lower cost option to try first. The first option must meet medical guidelines.</p> </div> </div> </div> </div> <div> <div class="component__cta"> <div data-cmp-is="cta"> <div class="cta__additionallinkswrapper count--1 "> <div class="link__column"> <h5 class="column__heading textUpper">CONDITIONS THAT OFTEN REQUIRE PRIOR AUTHORIZATION</h5> <ul> <li class="link__row"> <a class="link__digitaldownload color--default type__link__digitaldownload color--default " href="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/musculoskeletal-infographics.pdf" data-acmirenewaltype="Please Select" data-modal="Please Select" data-linktype="Regular" target="_blank" role="link" data-analytics-name="Musculoskeletal conditions prior authorization (PDF)" data-linklocation="discoverable" data-ctahrefholder="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/musculoskeletal-infographics.pdf">Musculoskeletal conditions prior authorization (PDF)</a> </li> <li class="link__row"> <a class="link__digitaldownload color--default type__link__digitaldownload color--default " href="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/neurological-infographics.pdf" data-acmirenewaltype="Please Select" data-modal="Please Select" data-linktype="Regular" target="_blank" role="link" data-analytics-name="Neurological conditions prior authorization (PDF)" data-linklocation="discoverable" data-ctahrefholder="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/neurological-infographics.pdf">Neurological conditions prior authorization (PDF)</a> </li> <li class="link__row"> <a class="link__digitaldownload color--default type__link__digitaldownload color--default " href="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/gynecologic-infographics.pdf" data-acmirenewaltype="Please Select" data-modal="Please Select" data-linktype="Regular" target="_blank" role="link" data-analytics-name="Gynecologic conditions prior authorization (PDF)" data-linklocation="discoverable" data-ctahrefholder="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/gynecologic-infographics.pdf">Gynecologic conditions prior authorization (PDF)</a> </li> <li class="link__row"> <a class="link__digitaldownload color--default type__link__digitaldownload color--default " href="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/skin-infographics.pdf" data-acmirenewaltype="Please Select" data-modal="Please Select" data-linktype="Regular" target="_blank" role="link" data-analytics-name="Skin conditions prior authorization (PDF)" data-linklocation="discoverable" data-ctahrefholder="/content/dam/aetna/pdfs/aetnacom/individuals-families/document-library/skin-infographics.pdf">Skin conditions prior authorization (PDF)</a> </li> </ul> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </section> <section class="content tab__panel tab__panel--dropShadow "> <div class="title--secondary tab__panel--mobile-btn" role="heading" aria-level="3" aria-controls="1518531389_panel_2"> <button type="button" aria-expanded="false">My request is in. What happens now?</button> </div> <div id="1518531389_panel_2" role="tabpanel" aria-labelledby="content_section_responsivegrid_1141134099_responsivegrid_tabs_link_tabs_2" class="content__component" tabindex="-1"> <div class="responsive-row"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="textwithmedia aem-GridColumn aem-GridColumn--default--12"><div class="textmedia " data-cmp-is-async="textwithmedia/one" data-content-well="yes" data-disablereadmore="true"> <div class="container textmedia__componentwrapper textmedia--one component--left textmedia--one--small"> <div class="row"> <div class="col-12 d-md-none"> <h4 class="title__block title--mobile">Next, we work with your doctor on your request</h4> </div> <div class="col-md-4 col-lg-4 mediawrapper__small__xsmall mediawrapper--left"> <div class="mediacontainer__slot1 "> <div data-src="/content/dam/aetna/asset-libraries/photos/GettyImages-1782472304_696x928.jpg" class="media__one__image media--hide"></div> <div class="media__one media__image--vertical" data-slot1-image-loaded="false"> <div class="media__content media__image--animate"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/photos/GettyImages-1782472304_696x928.jpg" alt width="696" height="928"/> </div> </div> </div> </div> <div class="col-md-6 col-lg-6 mediawrapper--right"> <div class="textmedia__wrapper"> <h4 class="d-none d-md-block title__block">Next, we work with your doctor on your request</h4> <div class="textmedia__wrapper--inner"> <div class="textmedia__text textmedia__text--top body__copy"><div class="textdescription text"><div class="rte-component-wraper component--default "> <p>We review each request against the highest quality clinical guidelines and scientific evidence. This includes:</p> <p> </p> <ul> <li>Guidelines from nationally recognized health care organizations</li> <li>Peer-reviewed, published medical journals</li> <li>Available studies on a particular topic</li> <li>Evidence-based consensus statements</li> <li>Expert opinions of health care professionals</li> </ul> <p>Want to learn more? We have over 800 <a data-analytics-name="clinical policy bulletins" href="/health-care-professionals/clinical-policy-bulletins.html" class="link__text--inline">clinical policy bulletins</a> that list the latest evidence-based guidelines. </p> <p> </p> <h5><span class="title--secondary">How long does prior authorization take? </span></h5> <p>The review typically takes about 14 days. Then, we’ll update you and your doctor with a decision. </p> <p> </p> <h5><span class="title--secondary">How do I track the status of my request?</span></h5> <p>You can log in to your member website to learn more. <a data-analytics-name="Log in to get updates" href="https://health.aetna.com/login?icid=aetnacom_ind-fam-prior-authorization-guidelines_what-happens-after-my-request-is-submitted" class="link__text--inline">Log in to get updates</a>. </p> <p> </p> <p>Don’t have an account? <a data-analytics-name="Register as a new user" href="https://health.aetna.com/register?icid=aetnacom_ind-fam-prior-authorization-guidelines_what-happens-after-my-request-is-submitted" class="link__text--inline">Register as a new user</a>. </p> </div> </div> </div> </div> <div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </section> <section class="content tab__panel tab__panel--dropShadow "> <div class="title--secondary tab__panel--mobile-btn" role="heading" aria-level="3" aria-controls="1518531389_panel_3"> <button type="button" aria-expanded="false">A decision is ready. What’s next?</button> </div> <div id="1518531389_panel_3" role="tabpanel" aria-labelledby="content_section_responsivegrid_1141134099_responsivegrid_tabs_link_tabs_3" class="content__component" tabindex="-1"> <div class="responsive-row"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="text aem-GridColumn aem-GridColumn--default--12"><div class="rte-component-wraper component--default "> <h4><span class="title__block">Let’s go over the next steps</span></h4> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-extra-small "> </span> </div> <div class="icontext aem-GridColumn--default--none aem-GridColumn aem-GridColumn--default--11 aem-GridColumn--offset--default--0"> <div class="texticon texticon__inherited "> <div class="texticon__container "> <div class="texticon__wrapper texticon__iconwrapper align-items-start"> <div class="texticon__icon icon__medium"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/icons_2021/icon_clipboard_with_checkmark.svg" alt/> </div> <div class="texticon__text rte-component-wraper inherited justified--left"> <h5><span class="title--secondary__big">If your request was approved</span></h5> <p style="text-align: left;">Our clinical experts agree with your provider’s treatment advice. There’s nothing else you need to do. Have questions? Call your provider or the number on your Aetna® ID card. We’re here to help.</p> </div> </div> </div> </div> </div> <div class="icontext aem-GridColumn--default--none aem-GridColumn aem-GridColumn--default--11 aem-GridColumn--offset--default--0"> <div class="texticon texticon__inherited "> <div class="texticon__container "> <div class="texticon__wrapper texticon__iconwrapper align-items-start"> <div class="texticon__icon icon__medium"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/icons_2021/icon_form_considering.svg" alt/> </div> <div class="texticon__text rte-component-wraper inherited justified--left"> <h5><span class="title--secondary__big">If your request was not approved</span></h5> <p>You’ll receive a letter from us explaining why the request wasn’t approved. In some cases, we may need more info. Other times, guidelines for medical need might not be met. If you disagree with the decision, know that you have options. You can:</p> <p> </p> <p> </p> <ul> <li>Request a peer-to-peer review. This review is a conversation between your care provider and an Aetna medical director. They can discuss the guidelines for medical need for your request. Your provider can also share more medical information.</li> <li>Request a formal appeal. Your letter from us includes steps to request a formal appeal. For more help, check out our <a data-analytics-name="claims appeal resources" href="/individuals-families/member-rights-resources/claim-denials.html" class="link__text--inline" target="_self">claims appeal resources</a>.</li> </ul> <p> </p> </div> </div> </div> </div> </div> </div> </div> </div> </section> </div> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-extra-small "> </span> </div> <div class="nextbestaction aem-GridColumn aem-GridColumn--default--12"><div class="nextaction " data-content-well="yes"> <div class="container nextaction__wrapper"> <div class="row "> <div class="col-md-12"> <div class="row"> <div class="col col-lg-6 nextaction__block--title "> <h2 class="title__block">Prior authorization resources</h2> </div> </div> </div> <div class="col-lg-3 col-md-6 nextaction__block--withtitle nextaction__block link--textline"> <div class="nextaction__top"> <div class="nextaction__top__icon"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/pictograms_2021/Pictogram_onWhite_Members_older2.svg" alt/> </div> <div class="nextaction__top__headline"> <h3 class="intro__copy">For Medicare members</h3> </div> </div> <div class="nextaction__body"> <div class="nextaction__body__description rte-component-wraper"> <p>Here’s a guide to understand prior authorization and the steps to take.</p> </div> </div> <div class="nextaction__body__textlink"> <div class="component__cta"> <div data-cmp-is="cta"> <div class="cta__linkswrapper "> <a class="link__text type__link__text " href="https://education.aetnamedicare.com/article/benefit-spotlight/prior-authorization-what-to-know" data-modal="Please Select" data-linktype="Regular" target="_self" role="link" data-analytics-name="Prior authorization: What you need to know" data-linklocation="discoverable" data-ctahrefholder="https://education.aetnamedicare.com/article/benefit-spotlight/prior-authorization-what-to-know" aria-label="What Medicare members need to know about prior authorization">Prior authorization: What you need to know</a> </div> </div> </div> </div> </div> <div class="col-lg-3 col-md-6 nextaction__block--withtitle nextaction__block link--textline"> <div class="nextaction__top"> <div class="nextaction__top__icon"> <img class=" lazyload" data-src="/content/dam/aetna/asset-libraries/pictograms_2021/Pictogram_onWhite_Group-of-people.svg" alt/> </div> <div class="nextaction__top__headline"> <h3 class="intro__copy">For everyone</h3> </div> </div> <div class="nextaction__body"> <div class="nextaction__body__description rte-component-wraper"> <p>Learn how prior authorization can help improve member care and safety.</p> </div> </div> <div class="nextaction__body__textlink"> <div class="component__cta"> <div data-cmp-is="cta"> <div class="cta__linkswrapper "> <a class="link__text type__link__text " href="/employers-organizations/resources/understanding-prior-authorization.html" data-modal="Please Select" data-linktype="Regular" target="_self" role="link" data-analytics-name="Understanding prior authorization" data-linklocation="discoverable" data-ctahrefholder="/content/aetna/en/employers-organizations/resources/understanding-prior-authorization.html">Understanding prior authorization</a> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> </div> <div class="reference parbase"> <div class="cq-dd-paragraph"><div class="disclaimer_copy disclaimer"><div class="cmp-disclaimer component--left" data-cmp-is-async="disclaimer"> <div class="container"> <div class="row"> <div class="col-md-10 disclaimer__parentContainer"> <div class="disclaimer__wrapper option-b"> <div class="row--inner"> <div class="disclaimer__contentwrapper disclaimer__contentwrapper--wide"> <h2 class="title__section">Legal notices</h2> <div class="disclaimer__description"> <div class="rte-component-wraper component--default " data-linklocationGeneral="discoverable"> <p>Aetna is the brand name used for products 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The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.</p> <p>Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.</p> <p>The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.</p> <p>Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.</p> <p>Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I Accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box " id="exit-cvs-caremark" role="dialog" title="Aetna® is proud to be part of the CVS® family." tabindex="-1" aria-labelledby="modal-heading-28807244"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-28807244" class="title__block ">Aetna® is proud to be part of the CVS® family.</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>You are now being directed to CVS Caremark<sup>®</sup> site.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">Continue</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="asam-modal" role="dialog" title="ASAM Terms and conditions" tabindex="-1" aria-labelledby="modal-heading-1817940071"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1817940071" class="title__block ">ASAM Terms and conditions</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <p>Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.</p> <p> </p> <p>This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose.</p> <p> </p> <p>Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="cpt-modal" role="dialog" title="Precertification lists" tabindex="-1" aria-labelledby="modal-heading-1737369633"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1737369633" class="title__block ">Precertification lists</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <p>Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".</p> <p> </p> <ul> <li>The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.</li> <li>Applies to: Aetna Choice<sup>®</sup> POS, Aetna Choice POS II, Aetna Medicare<sup>℠</sup> Plan (PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund<sup>®</sup> products, Aetna Health Network Only<sup>℠</sup>, Aetna Health Network Option<sup>℠</sup>, Aetna Open Access<sup>®</sup> Elect Choice<sup>®</sup>, Aetna Open Access HMO, Aetna Open Access Managed Choice<sup>®</sup>, Open Access Aetna Select<sup>℠</sup>, Elect Choice, HMO, Managed Choice POS, Open Choice<sup>®</sup>, Quality Point-of-Service<sup>®</sup> (QPOS<sup>®</sup>), and Aetna Select<sup>℠</sup> benefits plans and all products that may include the Aexcel<sup>®</sup>, Choose and Save<sup>℠</sup>, Aetna Performance Network or Savings Plus networks. Not all plans are offered in all service areas.</li> <li>All services deemed "never effective" are excluded from coverage. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search."</li> <li>The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT<sup>®</sup>), copyright 2023 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.</li> <li>The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.</li> </ul> <p> </p> <h3><strong>LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT<sup>®</sup>")</strong></h3> <p> </p> <ul> <li>CPT only Copyright 2023 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.</li> </ul> <p> </p> <h3><strong>U.S. Government Rights</strong></h3> <p> </p> <ul> <li>This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.</li> </ul> <p> </p> <h3><strong>Disclaimer of Warranties and Liabilities.</strong></h3> <p> </p> <ul> <li>CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.</li> <li>This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.</li> <li>Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".</li> <li>The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.</li> <li>This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.</li> </ul> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="dcpb-modal" role="dialog" title="Dental clinical policy bulletins" tabindex="-1" aria-labelledby="modal-heading-1767983030"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1767983030" class="title__block ">Dental clinical policy bulletins</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <ul> <li>Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.</li> <li>While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.</li> <li>Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.</li> <li>Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.</li> <li>Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.</li> </ul> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="mcpbs-modal" role="dialog" title="Medical clinical policy bulletins" tabindex="-1" aria-labelledby="modal-heading-1142802819"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1142802819" class="title__block ">Medical clinical policy bulletins</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default " data-linklocationGeneral="discoverable"> <p>Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".</p> <p> </p> <ul> <li>Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.</li> <li>While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental, investigational, unproven, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).</li> <li>Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.</li> <li>CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.</li> <li>Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.</li> <li>In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. </li> </ul> <p><a href="https://www.cms.gov/Center/special-topic/medicare-coverage-center.html" target="_blank" class="link__text" data-analytics-name="See CMS's Medicare Coverage Center" data-modal="exit" data-linktype="Regular">See CMS's Medicare Coverage Center</a></p> <p> </p> <ul> <li>Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.</li> <li>Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. Under certain circumstances, your physician may request a peer to peer review if they have a question or wish to discuss a medical necessity precertification determination made by our medical director in accordance with Aetna’s Clinical Policy Bulletin.</li> <li>While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans.</li> </ul> <p><a href="/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html" target="_self" class="link__text" data-analytics-name="See Aetna's External Review Program" data-modal="Please Select" data-linktype="Regular">See Aetna's External Review Program</a></p> <p> </p> <ul> <li>The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.</li> <li>The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.</li> </ul> <p> </p> <h3>LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")</h3> <p> </p> <p>CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.</p> <p> </p> <p>You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.</p> <p> </p> <p>Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.</p> <p> </p> <p><a href="http://www.ama-assn.org/go/cpt" target="_blank" class="link__text" data-analytics-name="Go to the American Medical Association Web site" data-modal="exit" data-linktype="Regular">Go to the American Medical Association Web site</a></p> <p> </p> <h3><strong>U.S. Government Rights</strong></h3> <p> </p> <p>This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.</p> <p> </p> <h3><strong>Disclaimer of Warranties and Liabilities.</strong></h3> <p> </p> <p>CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.</p> <p> </p> <p>This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.</p> <p> </p> <p>Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".</p> <p> </p> <p>The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.</p> <p> </p> <p>This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box " id="provault-modal" role="dialog" tabindex="-1" aria-labelledby="modal-heading-307478118"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-307478118" class="title__block "></h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <h2><span class="title__block">You are now leaving the Aetna® website.</span></h2> <p> </p> <p>We're working with 3Won to process your request for participation. 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Aetna Inc. and its affiliates are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">Continue to ProVault</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box " id="footnote-testing" role="dialog" title="You are now leaving the Aetna® website" tabindex="-1" aria-labelledby="modal-heading-549737117"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-549737117" class="title__block ">You are now leaving the Aetna® website</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>Links to various non-Aetna sites are provided for your convenience only. 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