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Autorización previa

Some types of care need prior authorization (PA), or approval, before you receive them*. Read on to learn more about PA.

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¿Tiene preguntas?

Just call us at 1-833-711-0773 (TTY: 711).We’re here for you 24 hours a day, 7 days a week.

¿Qué es la autorización previa?

¿Qué es la autorización previa?

Some services and supplies need approval from your health plan first. This means your providers need permission to provide certain services. They’ll know how to do this. We’ll work together to make sure the service is what you need.

 

Before the date you get care, you’ll need PA for these services:

 

  • Inpatient care in a hospital
  • Intensive home-based treatment
  • Partial hospital stay
  • Care in a psychiatric residential treatment facility  
  • Services from a non-participating provider (except emergency services)

 

This list doesn’t include all services that need PA. For more information, call us at 1-833-711-0773 (TTY: 711).

 

You need PA for all out-of-network services, except for emergencies. If you don’t get PA, you may have to pay for services that:

 

  • Brinda un proveedor fuera de la red.
  • Necesitan autorización previa.
  • que su plan no cubre.

Your provider must check to see if a service needs PA before they provide it. They can get the full list of services on their Provider Portal.

How we conduct medical reviews

We use certain medical review data as needed for behavioral health medical necessity decisions. These include: 

 

  • Criteria required by applicable state or federal regulatory agencies
  • Aetna® Medicaid Pharmacy Guidelines
  • Milliman Care Guidelines (MCG)  
  • Level of Care Utilization System (LOCUS) – behavioral health services for adults
  • Children and Adolescent Level of Care Utilization System (CALOCUS)
  • American Society of Addiction Medicine (ASAM) – substance use disorder services
  • Aetna Clinical Policy Bulletins (CPBs) on Aetna.com
  • Aetna Clinical Policy Council Review

For a copy of our review criteria, you can call 1-833-711-0773 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.

Cómo funciona la autorización previa

Cómo funciona la autorización previa

Esto es lo que puede esperar del proceso de autorización previa:

 

  • Your provider will give us information about the services they think you need.

  •  A health plan clinician will review the information.

  • If they can’t approve the request, a health plan Medical Director will review the information.

  • Your provider can discuss the determination with the health plan Medical Director.
  • You and your provider will get a letter when we deny a service.
  • Si rechazamos su solicitud, en la carta le explicaremos los motivos.

  • Si rechazamos una solicitud, usted o su proveedor podrán presentar una apelación.

El cuidado adecuado en el lugar y el momento justos

El cuidado adecuado en el lugar y el momento justos

PA is a type of utilization management (UM). It allows us to be sure you’re getting the right care at the right place and time, before you get it.

 

UM is the process we use to make sure you get covered quality services that are medically necessary. We also use national guidelines to be sure we’re doing the right thing. We make decisions about health care based on:

 

  • El cuidado más adecuado

  • los servicios disponibles;

  • la cobertura de beneficios.

We don’t reward any providers or staff for denying coverage or services. We also don’t give money to providers or staff to make decisions that keep you from getting the right care. And finally, we don’t hire, promote or end contracts with providers based on the likelihood they’ll deny your benefits. Our goal is to help you be as healthy as you can be. So, we want you to have the right care.

 

You and your provider can talk about all treatment options and whether we cover them or not.

 

You can get the most current list of treatment options, too. Just check your member handbook on our member materials and forms page. Or call us at 1-833-711-0773 (TTY: 711). We’re here 24 hours a day, 7 days a week.

* We will provide 30-calendar days advance notice of changes to the list of all services requiring prior authorization.