Prior authorization

Prior authorization

There may be a time when you have a health problem that can’t be treated by your primary care physician (PCP) alone. Sometimes you may need specialty care or to see a specialist.

  • Prior authorization is a request to Aetna Better Health of Ohio for you to get special services.  
  • The provider giving you the service requests prior authorization before the service is rendered.
  • You do not need a referral or prior authorization to get emergency services.

How it works
Aetna Better Health of Ohio providers follow prior authorization guidelines. If you need help understanding any of these guidelines, please call Member Services or your care manager.

  • Aetna Better Health of Ohio reviews urgent prior authorization requests in up to 48 hours from when we receive the request.  It may take up to 10 days to review a routine prior authorization request.
  • If we need more information, we may ask for a 14-day extension. If we do not get the requested information from the requesting provider, we may deny the request. If this happens you will receive a Notice of Denial letter that explains your appeal rights. 
  • If your provider makes an urgent prior authorization request and it does not meet the urgent criteria, we will send you a letter to let you know it will be processed as a routine request. You can make a complaint, if you disagree.

If you have questions about your service authorizations, call your PCP, your care manager or Member Services.  

Important information for Aetna Better Health of Ohio members who need specialty services

Some outpatient services and planned hospital admissions need prior authorization before the service can be covered. Please see the Medicare-Medicaid Member Handbook/Evidence of Coverage in English or Spanish for more information about what requires prior authorization.