Prior authorization

Aetna Better Health of Ohio requires prior authorization for select acute outpatient services and planned hospital admissions. To view a list of services that require prior authorization please review our Prior Authorization List.  

Prior authorization is not required for emergency services. To request a prior authorization, be sure to:

  • Always verify member eligibility prior to providing services.
  • Complete the appropriate authorization form (medical or pharmacy).
  • Attach supporting documentation when submitting.

If covered services and those requiring prior authorization change, you will receive at least 60 days’ advance notice via provider newsletter, e-mail, updates to this website, letter (U.S. mail), telephone call or office visit.

Remember, prior authorization is not a guarantee of payment. Unauthorized services will not be reimbursed.

To request an authorization, find out what services require authorization, or to check on the status of an authorization, please visit our portal page. For more information about prior authorization, please review your Provider Manual.

You can fax your authorization request to 1-855-734-9389.

For assistance in registering for or accessing this site, please contact your Provider Relations representative at 1-855-364-0974.

When you request prior authorization for a member, we’ll review it and get back to you according to the following timeframes:

  • Routine – 10 calendar days upon receipt of request
  • Urgent – Within 48 hours upon receipt of request

*An urgent request is appropriate for a non-life-threatening condition that will result in a worsened or more complicated condition if it’s not treated promptly. We encourage you to call the Prior Authorization department at 1-855-364-0974 for all urgent requests.

Participating providers can now check for codes that require prior authorization via our Online Prior Authorization Search Tool.

Provider notification – New prior authorization RE: Power wheelchairs

Dear Valued MyCare Ohio Provider, 

Effective 10/25/2024, Aetna Better Health of Ohio will require prior authorization for the CPT Code K0823, typically used in conjunction with Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds. This change is intended to ensure the safety, medical necessity, and appropriateness of requested procedures. As always, do not hesitate to contact Aetna Better Health of Ohio with any questions or comments at 1-855-364-0974. Thank you for your valued partnership in caring for our Aetna Better Health Members. 

Subcontractors

Aetna Better Health of Ohio works with certain subcontractors to coordinate services that are provided by entities other than the health plan, such as transportation, vision or dental services. If you have a member who needs one or more of these services, please contact Member Services at 1-855-364-0974 for more information.

 

Nursing Facility Prior Authorization/Level of Care

To minimize confusion and create a standard process for nursing facilities to request PA/LOC, the Nursing Facility Request Form was developed in collaboration with the Ohio Department of Medicaid. Additional details can be found here.