Aetna Prior Authorization List for Addiction Treatment and More

Aetna has a list of prior authorization requirements for addiction treatment, which may vary depending on the state and specific treatment center.

In some cases, patients may need to undergo a comprehensive assessment to determine the level of care needed.

Aetna's prior authorization list includes medication-assisted treatment for opioid use disorder, such as methadone and buprenorphine.

This means that patients may need to try other forms of treatment before being approved for medication-assisted therapy.

Aetna Prior Authorization Requirements are in place to ensure that certain procedures and services are approved before they are administered. This applies to procedures and services on the Aetna Participating Provider Precertification List.

To submit a precertification, you can use electronic data interchange (EDI), the secure provider website, or by phone using the number on the member's ID card. You can also check the precertification lists on the Aetna website.

The types of procedures and services that require precertification include those on the Aetna Behavioral Health Precertification List, as well as procedures and services that require precertification under the terms of a member's plan.

When we require precertification, it's essential to know what procedures and services fall under this category. Precertification is necessary for procedures and services on the Aetna Participating Provider Precertification List.

You can find the specific procedures and services that require precertification by checking our precertification lists. Precertification also applies to procedures and services on the Aetna Behavioral Health Precertification List.

If your member's plan requires precertification for certain procedures and services, that's another reason to submit a precertification request. Any organization determination requested by a Medicare Advantage member, appointed representative, or physician for a coverage decision also requires precertification.

You can submit a precertification request by electronic data interchange (EDI), through our secure provider website, or by phone using the number on the member's ID card.

Dental Clinical Policy Briefs are developed by Aetna to assist in administering plan benefits, but they don't constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members.

Members should discuss any Dental Clinical Policy Brief related to their coverage or condition with their treating provider. This ensures that they understand the policy and its implications for their care.

Aetna's Dental Clinical Policy Briefs are regularly updated and are subject to change. This means that the information in the briefs may not always be up-to-date.

The briefs can be highly technical and are designed to be used by Aetna's professional staff in making clinical determinations in connection with coverage decisions. Members should review these briefs with their providers so they may fully understand Aetna's policies.

Here are some key things to keep in mind when reviewing Dental Clinical Policy Briefs:

Aetna's precertification requirements for addiction treatment can be confusing, but there are some key facts to keep in mind.

Aetna no longer requires precertification for intensive outpatient and outpatient detoxification services, which correspond to CPT codes H0015 and H0014.

According to Aetna's Behavioral Health Precertification List, these services were exempt from precertification requirements starting in 2019.

You may be tempted to use Aetna's "search by CPT code" function to determine if precertification is required, but unfortunately, this tool is not reliable for addiction treatment providers.

Aetna's search tool will return a "precertification not required" statement for all addiction treatment CPT codes, but this is misleading.

In fact, the tool will often include a message at the bottom stating that the code may require precertification for behavioral health diagnoses, which is the opposite of what you want to hear.

To avoid confusion, it's best to rely on Aetna's Behavioral Health Precertification List or consult with a specialist, such as BehaveHealth's Revenue Cycle Management team, which can handle all aspects of addiction treatment billing, including precertification requirements.

Here are the specific CPT codes that should not require precertification from Aetna for addiction treatment:

Aetna requires precertification for addiction treatment centers, both participating and out-of-network providers, before admitting patients.

Precertification is the process of getting permission from Aetna before seeking or administering treatment, and it involves checking that the specific treatment is covered for the patient.

Aetna's precertification process also includes checking the coverage details for the patient.

Aetna generally requires addiction treatment centers to obtain precertification before admitting patients.

There are some exceptions to Aetna's precertification requirements, including intensive outpatient and outpatient detoxification services, which are not required to have precertification.

These services are exempt from precertification requirements due to state and federal laws.

The CPT codes for these services, H0015 and H0014, do not require in-network precertification from Aetna.

However, Aetna's "search by CPT code" function on its website can be misleading, as it indicates that all addiction treatment CPT codes do not require precertification.

In reality, this function is not reliable for addiction treatment providers, and Aetna's message at the bottom of the search result page clarifies that the code may require precertification for behavioral health diagnoses.

Here are some services that do not require precertification from Aetna:

Intensive outpatientOutpatient detoxification (aka ambulatory withdrawal management)

Note that Aetna's precertification requirements can be complex and require attention to detail.

To get your prescription drugs covered by Aetna, you need to follow certain rules.

Some drugs require prior authorization, which means you or your doctor needs approval from Aetna before they'll cover the drug.

For certain drugs, there's a limit on how much you can fill within a certain time frame. For example, 60 tablets per 30-day prescription.

We require you to try another drug first before we cover your drug, a process called step therapy.

Here are some examples of coverage rules: