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Prior authorization

Some types of health care need to be preapproved by your Provider. We’ll connect you to the right care when you need it. 

Prior authorization may also be referred to as a coverage decision (determination).

What is prior authorization?

What is prior authorization?

Some care will require your Provider to get our approval first. This process is called prior authorization or preapproval. Some common services that need prior authorization include:

 

  • Certain outpatient services and planned hospital admissions 

  • Services outside your network that in-network providers are unable to provide
  • Major surgeries

  • Specialist visits 

  • Expensive medications

  • Some Durable Medical Equipment (DME) and related supplies

How prior authorization works

How prior authorization works

Aetna Assure Premier Plus (HMO D-SNP) has specific prior authorization guidelines and certain steps are needed to obtain an approval in advance: 

 

  • Your Primary Care Provider (PCP) will tell us about the services you may need.

  • Aetna Assure Premier Plus (HMO D-SNP) will review the claim.

  • We will make a decision within 14 calendar days or 72 hours for urgent requests.
  • For Part B drugs, we will make a decision within 72 hours or 24 hours for urgent requests.

  • You and your provider will get a letter telling you if the service has been approved or denied and provide a reason for the decision.

  • If a service is denied, you or your provider, with your written permission, can file an appeal. 

If you have any questions about these guidelines, you can call Member Services at 1-844-362-0934 (TTY: 711).

Members must use participating/network providers, pharmacies, and durable medical equipment (DME) suppliers. No referral is required to receive covered services by in-network providers.

Have a question?

You can learn more about prior authorization by calling Member Services at 1-844-362-0934 (TTY: 711).

 

Need to request prior authorization? Visit our Complaints, coverage decisions and appeals page for details.