Aetna's Utilization Management program is designed to help you evaluate the medical necessity of your recommended treatment and identify whether or not a procedure can be certified under the terms of your plan.
You’ll need to receive approval before you obtain certain treatments, services and/or supplies in order for you to qualify for full medical benefits.
During the precertification review process, our staff can help you or your doctor answer important questions, such as:
- Is the proposed treatment or service a covered benefit under your plan?
- Are the proposed health care providers considered in-network doctors under your plan?
- Does the request for clinical services follow evidence-based clinical protocols specific to the medical information provided?
Of course, any decision regarding treatment is left up to you and your doctor. Precertification review can help you make a more informed decision before undergoing any recommended treatments.
How Precertification Review Works
- If your doctor recommends a treatment or service that requires precertification, remind him or her that you will need to obtain precertification.
- You or your doctor should call the precertification phone number listed on your ID card prior to a scheduled treatment. If you are admitted to the hospital on an emergency basis, call the precertification phone number by the second business day following admission.
- When you call, the precertification staff will review the diagnosis, recommended treatment and proposed level of care.
- If necessary, the review staff will contact your doctor for additional medical information.
- You, your doctor and/or the hospital will be notified in writing of the review decision.
If You Have Questions
Please refer to your Official Plan Brochure for your plan's specific precertification requirements or call us toll free at 800-638-8432.
Official Plan Brochure
Download a copy of our Official Plan Brochure to learn more.