Precertification requirements

The decision to receive care is between you and your provider. If you do not precertify care when you are required to do so, your benefits will be reduced, or in some instances, not paid at all.

  • If you are in a PPO Option and you use a network provider for covered medical care, the provider will take care of precertification for you.
  • If you use a NAP provider, confirm that the provider is obtaining precertification on your behalf; otherwise contact Aetna directly for precertification. (The NAP Program is a discount program and does not guarantee precertification.)
  • In all other instances, you are responsible for obtaining any required precertification.

Precertification is not required for expenses incurred while you are outside the United States.

It is a good idea to provide a family member, friend and/or your doctor with the precertification instructions. That way, they will be able to make the precertification call for you in case you cannot. Even if you rely on someone else to make the call for you, it is your responsibility to follow up to be sure the call was made. Precertification is required for the following services:

  • Inpatient admissions. Non-emergency hospital (including hospitalization for mental health/substance abuse treatment), skilled nursing facility, and hospice admissions must be precertified by calling the claims administrator at the toll-free precertification number shown on your medical option ID card (at least 10 days in advance for Aetna).
  • Maternity stays. Precertification of maternity care is not required. If your doctor recommends an extended stay beyond 48 hours for a vaginal delivery or 96 hours for a Caesarean section, the additional days must be precertified with the claims administrator within 48 hours (or two business days). If the mother is discharged before the baby is allowed to go home, the baby’s extended stay must also be precertified.
  • Hospitalization due to a medical emergency. You must certify by calling the claims administrator within 48 hours (or two business days) of your emergency admission.
  • Enhanced clinical review (NOTE: Applies only to Aetna PPO Options). Certain services (listed below) are subject to enhanced clinical review through a separate independent company. This company uses medical specialists and diagnostic tools to review your doctor’s request, applying national medical standards, with the initial review accomplished typically within 24 hours of the request. Your doctor should submit a request for clinical review for the following services:
    • Cardiac imaging, including non-urgent outpatient diagnostic catheterization and echo stress tests.
    • Cardiac rhythm implantable devices.
    • Sleep studies.
    • Radiation oncology therapy.
    • High-tech radiology, including MRI/MRA, CT scan, PET scan and nuclear imaging.
    • Outpatient interventional pain management.
    • Hip and knee replacements (inpatient and outpatient).

Responsibility for obtaining preauthorization of the above services is shared by the patient (or the parent plan participant, if a child), the referring physician and the facility rendering the service. In-network physicians have been engaged regarding this requirement and should be aware of the process.

  • Outpatient medical services. Some outpatient procedures, including outpatient hospice care, home health care and private duty nursing and, in some circumstances, outpatient rehabilitation services require precertification. Additionally, if your doctor recommends an intensive outpatient program for psychiatric, eating disorder care and/or substance abuse care that is generally two or more hours per day, precertification is required. If your doctor recommends these outpatient services, you or your doctor should call the toll-free precertification number shown on your medical option ID card in advance to make sure the procedure is covered by the plan.
  • Partial hospitalization or a day program. Outpatient care focused on psychiatric, eating disorder care and/or substance abuse care that is generally four or more hours per day and includes individual, group and family therapies must be precertified in advance by calling the claims administrator at the toll-free precertification number shown on your medical option ID card.
  • Electroconvulsive therapy treatment (ECT). ECT is systematic use of electric shocks to produce convulsions. Care must be precertified in advance by calling the claims administrator at the toll-free precertification number shown on your medical option ID card.
  • Psychological testing. Psychological testing must be precertified by calling the claims administrator at the toll-free precertification number shown on your medical option ID card.
  • Biofeedback. Biofeedback must be precertified by calling the claims administrator at the toll-free precertification number shown on your medical option ID card.
  • Outpatient detoxification. Outpatient detoxification must be precertified by calling the claims administrator at the toll-free precertification number shown on your medical option ID card.  

See Process for formal benefit claims and appeals if you receive an adverse benefit determination with respect to your request for precertification.

Precertification penalties

If you do not precertify care (including behavioral health care) when you are required to do so, your benefits will be reduced or, in some instances, not paid at all. Specifically, the following penalties will apply:

  • If you do not call to precertify. All expenses related to care that has not been precertified are reviewed by the claims administrator. Benefits will not be paid for any expenses (including room and board) that were not medically necessary. A $300 penalty will be deducted from any benefits that are otherwise payable.
  • If you call to precertify, but the claims administrator determines that your admission, proposed treatment or expense is not medically necessary: No benefits will be paid.
  • If you call to precertify additional hospital days beyond those initially precertified, but the claims administrator determines that those additional days are not medically necessary: No benefits will be paid for the additional days.

Because PPO network providers are responsible for obtaining precertification of care for you, precertification penalties do not apply under the BP PPO Options for eligible care received from a network provider. However, if you are intending to receive an in-network level of benefits, it is your responsibility to confirm that each provider or facility you use is in the Aetna Choice POS II network. If a provider practices at multiple locations, he/she may not be considered an in-network provider at each location. Confirm with the provider that he/she is in the network at the location you intend to visit before receiving care.

 

Publication date: April 2019

 

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