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. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
The member's benefit plan determines coverage. 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. 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. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. Aetna will review the additional information along with the original submission and render a determination.Īetna will review the request and render a determination within Missouri statutory time frames.īy clicking on “I Accept”, I acknowledge and accept that: Aetna will review the additional information along with the original submission and render a determination.Īfter the member has been discharged from an acute inpatient event and an adverse determination was issued due to lack of clinical information to support medical necessity, and clinical information is received within five (5) business days of hospital discharge but prior to peer-to-peer review or appeal request. While the member is receiving ongoing concurrent inpatient or ambulatory services, or within five (5) days of termination of these services.
Aetna will review the additional information along with the original submission as a new precertification request. When received more than 14 days from the date of the denial letter for services that have not yet started and the missing information is received within six (6) months of the date of the denial letter.When received within fourteen (14) calendar days of the letter of noncertification and peer to peer review has been completed.Aetna will review the additional information with the original request and make a determination based on all information received at that time. When received within fourteen (14) calendar days of the letter of noncertification and peer to peer review has not been completed for services that have not yet begun.
If a request for authorization is not certified due to lack of clinical information required to make a medical necessity determination and no appeal has been submitted, we will review the request with additional information as follows: This will apply in cases where no information is received or if some clinical information is submitted but is inadequate to approve a request for authorization.Īdministrative denials for lack of clinical information If the requested information is not received, an administrative denial for lack of clinical information will be made. We may require submission of clinical information to confirm medical necessity of the requested service, treatment, procedure, diagnostic service, therapy, ambulatory or inpatient service. We cover medically necessary treatment, procedures, therapies and diagnostic ambulatory and inpatient services. Alternatively, you can call Member Services to find the services requiring prior authorizations. You can find Aetna’s precertification list on our provider website. The Aetna ® PCP or network provider is responsible for obtaining this approval for covered in-network services. Sometimes we will pay for care only if we have given an approval before a member receives care.
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