Precertification Guide for Aetna Health Plans

This document is a guide for healthcare providers regarding the precertification process for patients enrolled in Aetna health plans, effective November 1, 2024. It outlines the procedures, services, and medications that require prior authorization, also known as precertification. The guide includes instructions on how to submit precertification requests, emphasizing the importance of completing all required sections and submitting requests at least two weeks in advance. It details the use of the Availity provider portal for online submissions and provides contact information for inquiries related to the precertification process. The document also specifies that certain services, such as inpatient confinements and elective procedures, are subject to medical necessity reviews. Additionally, it notes that precertification is not required for some outpatient services for specific plans and provides information on coverage determinations based on CMS policies for Medicare Advantage members. The guide serves as a comprehensive reference for best practices when working with Aetna.