Aetna’s Medical Management Program
Managing your health includes getting the information you need to make informed decisions and making sure you get the maximum benefits the Plan will pay. To support you, Aetna provides Aetna’s Medical Management Program. This services precertifies certain treatments and procedures, such as hospital admission, to ensure you receive the highest quality of care for the right length of time, in the right setting and with the maximum available coverage.
Aetna’s Medical Management Program works with you and your provider to help confirm the medical necessity of services and help you make sound health care decisions.
HOW AETNA’S MEDICAL MANAGEMENT PROGRAM HELPS YOU
To help ensure that you receive the maximum coverage available to you, Aetna’s Medical Management Program:
- Reviews all planned and emergency hospital admissions
- Reviews ongoing hospitalization
- Performs case management
- Coordinates discharge planning
- Coordinates purchase and replacement of durable medical equipment, prosthetics and orthotic requirements
- Reviews inpatient and ambulatory surgery
- Reviews high-risk maternity admissions
- Reviews care in a hospice or skilled nursing or other facility
All other services will be subject to retrospective review by Aetna’s Medical Management team to determine medical necessity.
If Services Are Not Precertified
If you call to precertify services as needed, you will receive maximum benefits. Otherwise, benefits may be reduced by 50% up to $5,000 for each admission, treatment or procedure. This benefits reduction also applies to certain same-day surgery and professional services rendered during an inpatient admission. If the admission or procedure is not medically necessary, no benefits will be paid.
CALL TO PRECERTIFY THESE REQUIRED SERVICES
The boxes below show the health care services that must be precertified with Aetna’s Medical Management Program.
Maternity Care
- As soon as reasonably possible; we request notification within the first three months of pregnancy when possible
- Within 48 hours after the actual delivery date, if stay is expected to extend beyond the minimum length of stay for mother and newborn inpatient admission: forty-eight (48) hours for a vaginal birth or ninety-six (96) hours for Cesarean birth
Newborns
- Standard length of stay for vaginal deliveries is a total of three days or less
- Standard length of stay for Cesarean section is a total of five days or less
There is no precertification for intensive outpatient programs. Outpatient treatments and durable medical equipment will require precertification based on the services/equipment received. Find out more about precertification on www.aetna.com or www.aetna.com/health-care-professionals/precertification/precertification-lists.html.
INITIAL DECISIONS
Aetna will comply with the following time frames in processing precertification, concurrent and retrospective review of requests for services.
- Precertification Requests. Precertification means that Aetna’s Medical Management Program must be contacted for approval before you receive certain health care services that are subject to precertification. We will review all nonurgent requests for precertification within three business days of receipt of all necessary information but not to exceed 15 calendar days from the receipt of the request. If we do not have enough information to make a decision within 15 calendar days, a clinical denial of coverage is rendered. The letter you receive will tell you how to appeal to denial of coverage decision.
- Urgent Precertification Requests. If the need for the service is urgent, we will render a decision as soon as possible, taking into account the medical circumstances, but in any event within 72 hours of our receipt of the request. If the request is urgent and we require further information to make our decision, we will notify you within 24 hours of receipt of the request and you and your provider will have 48 hours to respond. We will make a decision within 48 hours of our receipt of the requested information, or if no response is received, within 48 hours after the deadline for a response.
- Concurrent Requests. Concurrent review means that Aetna reviews your ongoing care during your treatment or hospital stay to be sure you get the right care in the right setting and for the right length of time. When the request to continue care is received at least 24 hours before the last approved day, we will complete all concurrent reviews of services within 24 hours of our receipt of the request.
- Retrospective Requests. Retrospective review is conducted after you receive medical services. We will complete all retrospective reviews of services already provided within 30 calendar days of our receipt of the claim. If we do not have enough information to make a decision within 30 calendar days, a clinical denial of coverage is rendered. The letter you receive will tell you how to appeal the denial of coverage decision. If Aetna’s Medical Management Program does not meet the above time frames, the failure should be considered a denial. You or your doctor may immediately appeal.
IF A REQUEST IS DENIED
All denials of benefits will be rendered by qualified medical personnel. If a request for care or services is denied for lack of medical necessity, or because the service has been determined to be experimental or investigational, Aetna’s Medical Management Program will send a notice to you and your doctor with the reasons for the denial. You will have the right to appeal. Refer to the “Complaints, Appeals and Grievances” section of your medical benefits booklet for more information.
If Aetna’s Medical Management Program denies benefits for care or services without discussing the decision with your doctor, your doctor is entitled to ask Aetna’s Medical Management to reconsider their decision. A response will be provided by telephone and in writing within one business day of making the decision.