6.4 PRECERTIFICATION REVIEW
Certain health care services such as hospitalization, outpatient surgery and certain other outpatient services, require precertification.
- If you use an Aetna network provider, your provider is responsible for obtaining necessary precertification for you. Because precertification is the provider’s responsibility, if your provider fails to pre-certify required services, the provider’s reimbursement will be limited and the provider cannot pass those costs on to you.
- If you use a non-preferred provider, your provider may pre-certify for certain services on your behalf. If the provider fails to pre-certify those services, Aetna will review the medical necessity of those services when the claim is filed. If the service is not medically necessary or is otherwise not payable by this Plan and is not approved, no benefits will be paid. If the service is medically necessary and otherwise payable by this Plan, benefits will be paid according to the Plan’s limitations.
Precertification Review is a procedure administered by the Utilization Management Organization to assure that the admission and length of stay in a Hospital or specialized facility, surgery or other health care services are Medically Necessary. The Utilization Management Organization determines if recommended confinements, surgery or other health care services meet or exceed accepted standards of care.
If additional information is needed, the Utilization Management Organization will advise the caller. The Utilization Management Organization will review the information provided, and will let you, your Physician and the Hospital (or other provider), and the Administrative Office know whether or not the proposed services have been certified as Medically Necessary. The Utilization Management Organization will respond to your Physician or other provider by telephone shortly after the Utilization Management Organization receives the request and any required medical records and/or information, and the determination will then be confirmed in writing.