Precertification is the term that is used to call the process of collecting information before inpatient admissions and choose ambulatory procedures and services. This term applies to a few things, such as procedures and services on the Aetna participating provider precertification list and the Aetna behavioral health precertification list; any organization determination that is made by a Medicare Advantage member or created on behalf of the member by their appointed representative or physician for an advance coverage; and procedures and services that need precertification under the terms of a member’s plan.
There is a possibility of the procedures and services on the precertification lists to require a data entry process that does not require judgment or interpretation for benefits coverage called notification. Besides, it may also require a coverage determination that is based upon plan documents. When it is applicable, a review of clinical information to determine whether clinical guidelines or criteria for coverage are met.
During the coverage determination process, guidelines or criteria that is recognized nationally may be used. These include:
- Aetna Clinical Policy Bulletins (CPBs)
- Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and Medicare Benefit Policy Manual
- MCG guidelines
- American Society of Addiction Medicine (ASAM) criteria; Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition
- Level of Care Assessment Tool (LOCAT)
- Applied Behavior Analysis (ABA) Guidelines for the Treatment of Autism Spectrum Disorders
Apparently, the process of precertification helps Aetna in a few things, including in communicating coverage decisions practitioners, member and or member authorized representatives or appointed representatives before procedures, services or supplies are provided and in identifying and registering members for covered specialty programs, such as Aetna Health Connections SM case management and disease management, behavioral health, National Medical Excellence Program, and women’s health programs, including the Beginning Right Maternity Program as well as the infertility program.
Everyone should know that precertification applies to every benefit plan that includes a precertification requirement. It applies to the Aetna Participating Provider Precertification list and the Aetna Behavioral Health precertification list apply to participating providers. In the other words, the participating providers are the ones that are required to pursue precertification when it is required, instead of the members. Actually, a member’s plan may need the member to get precertification for specific procedures or services. For your information, this requirement is stated is the Certificate of Coverage of the member. IF it is not found there, it may be included in the Summary Plan Description. Take note that there is no need for a participating provider to get this requirement. Every Medicare Advantage member can request a pre-service coverage determination for any procedure to service that they believe is covered and should be furnished, arranged or reimbursed by Aetna. Not only the members, the members appointed representatives and providers can also do the same on behalf of the Medicare Advantage members.
Precertification is needed by all inpatient confinements and all procedures schedules at a nonparticipating freestanding ambulatory surgery center. In addition, it is also possible for the member’s plan to require precertification in case you are a nonparticipating physician, hospital or other health care professional.
Then, how to submit a precertification request? To be able to request precertification (or authorization), you will need behavioral health services, which include treatment for substance use disorders. An electronic precertification request can be submitted on the provider website of Aetna called Availity.com.
Apart from that, another way that you can do is to choose any other website that allows precertification requests. In order to see the vendor list, please visit Aetna.com/provider/vendor. Besides, you are also able to inquire electronically about the requests that you submitted previously.
Talking about precertification in Aetna Medicare, there is a thing called Medicare Aetna precertification. Medicare Aetna precertification tool is the name of the tool that is able to use in order to see if precertification is required. In addition, it is also helpful to determine if a special program applies. If you are new to this tool and want to know more about it, this page will explain everything about it for you.
For those who want to find the Medicare Aetna precertification tool, the first thing that you have to do is to go to the official website of Aetna at www.aetna.com. When you are on the site, find the search bar that is found on the right side of the page and type in the word “precertification” as the keyword. After entering the keyword, the next thing that should be done is to press Enter to get the result shown. Among the results shown, please choose the one entitled Precertification Lists CPT Code Lookup Aetna.
On the Precertification Lists page, you will be able to find the information about the precertification. If you want to use the Medicate Aetna precertification tool to see if precertification is required, scroll down a bit until you find something that is written “Search by CPT code”. Then, enter one or more 5 digit CPT codes and do not forget to press the purple Submit button after that. Make sure to enter a valid and current five digit CPT or HCPCS code to be able to get an appropriate response from this tool. There is no way for the tool to cover the invalid, deleted or expired codes.
One of the CPT codes is 90834. When you enter the code to the tool, you will be informed that the procedure that you entered was not found on the Aetna Participating Provider Medical Precertification List. If you are one of the participating providers, it should be noted that no precertification is needed when this service is performed as an outpatient procedure for a medical or surgical diagnosis. It is possible for this procedure code to need precertification for behavioral health diagnoses.
If you are wondering about the behavioral health services that need precertification or authorization, these include applied behavioral analysis (ABA), impatient admissions, partial hospitalization programs (PHPs), residential treatment center (RTC) admissions, and transcranial magnetic stimulation (TMS).