Participating Provider Precertification List
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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Participating Provider Precertification List Effective December 2, 2013 Applies to: all Aetna plans, except Traditional Choice plans. All Innovation Health SM plans.* Precertification** and notification are the processes of collecting information before elective inpatient admissions and/or selected ambulatory procedures and services take place. Therefore, requests for precertification and notification must be received before rendering services. Failure to contact the member s health plan (the health plan ) for precertification will relieve the health plan or employers and members from any financial liability for the applicable service(s), if those services are rendered. 1. Inpatient confinements Surgical and nonsurgical Skilled nursing facility Rehabilitation facility Inpatient hospice (except Medicare) Maternity and newborn confinements that exceed the standard length of stay (LOS)*** 2. Ambulance Transportation by fixed-wing aircraft (plane) Elective (non-emergent) transportation by ground ambulance or medical van for Medicare Advantage plan members only 3. Autologous chondrocyte implantation, Carticel 4. Cochlear device and/or implantation 5. Cognitive skills development 6. Customized braces 7. Dental implants and oral appliances * Not all plans are offered in all service areas and not all plans include all services listed. Innovation Health Insurance Company and Innovation Health Plan, Inc. (Innovation Health) are affiliates of Aetna Life Insurance Company (Aetna) and its affiliates. Aetna and its affiliates provide certain management services for Innovation Health. Precertification is required when Aetna or Innovation Health is secondary payer. ** The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company s clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. Notifications are not subject to clinical review. *** A total LOS of three days or less for vaginal deliveries. A total LOS of five days or less for a Cesarean section. All services deemed never effective are excluded from coverage. Aetna defines a service as never effective when it is not recognized according to Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Innovation Health Insurance Company and Innovation Health Plan, Inc. (Innovation Health) are affiliates of Aetna Life Insurance Company (Aetna) and its affiliates. Aetna and its affiliates provide certain management services for Innovation Health V (12/13)
2 8. Dialysis visits Call or fax applicable request forms to Dorsal column (lumbar) neurostimulators: trial or implantation* 10. Drugs and medical injectables Blood-clotting factors --Precertification for outpatient infusion of this drug class is required For the following services, call or fax applicable request forms to Actimmune Infertility medications (injectable) Acthar Gel Jevtana Adcetris Krystexxa Alpha 1-proteinase inhibitor human Makena Antiemetics: Multiple sclerosis drugs: --Palonosetron (Aloxi IV ), dolasetron (Anzemet IV ) and fosaprepitant (Emend IV ) Benlysta Botulinum toxin types A and B (Botox, Dysport, incobotulinumtoxin a, Myobloc, Xeomin ) Enzyme replacement drugs: --Precertification for outpatient infusion of this drug class is also required Erbitux Erythropoiesis-stimulating agents (ESA), such as darbepoetin alpha, epoetin alpha and epoetin beta Gattex Growth hormone Hereditary angioedema drugs Immunologic agents: --Actemra, Actemra SC, Amevive, Cimzia, Enbrel, Humira, Kineret, Orencia, Remicade, Rituxan, Simponi, Simponi Aria, Stelara --Xeljanz Immunoglobulins: --Any parenteral administration intravenous (IV), subcutaneous (SubQ) and/or intramuscular (IM) --Precertification for outpatient infusion of this drug class is required --Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Rebif, Tecfidera, Tysabri Osteoporosis drugs injectable: --Boniva, Forteo, Miacalcin and Prolia --Zometa, Reclast and pamidronate (Aredia ) (for osteoporosis indications only) Pegylated interferon alpha when used for hepatitis C: --Pegasys, PegIntron, Rebetron, Roferon-A, Intron A, Infergen Provenge Pulmonary arterial hypertension drugs Soliris Synagis Vectibix Viscosupplementation: --Euflexxa, Gel-One, Hyalgan, Orthovisc, Supartz, Synvisc, Synvisc-One Xgeva Xofigo Xolair Yervoy Zaltrap 11. Electric or motorized wheelchairs and scooters 12. Gastrointestinal (GI) tract imaging through capsule endoscopy* 13. Home health care related services Private duty nursing, maternity management home care and home uterine activity monitoring All home health care for Medicare Advantage plan members only Home hospice for Medicare Part B plan members only * All services deemed never effective are excluded from coverage. Aetna defines a service as never effective when it is not recognized according to
3 14. Hyperbaric oxygen therapy* 15. Limb prosthetics 16. Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider 17. Oncotype DX * 18. Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint 19. Osseointegrated implant* 20. Osteochondral allograft/knee* 21. Proton beam radiotherapy* 22. Reconstructive or other procedures that may be considered cosmetic Blepharoplasty/canthopexy/canthoplasty Breast reconstruction/breast enlargement Breast reduction/mammoplasty Cervicoplasty Chemical peels Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Injection of filling material Lipectomy or excess fat removal Sclerotherapy or surgery for varicose veins 23. Referral or use of nonparticipating physician or provider for non-emergent services, unless the member understands and consents to the use of a nonparticipating provider under their out-of-network benefits when available in their plan 24. Spinal procedures Artificial intervertebral disc surgery Cervical, lumbar and thoracic laminectomy/laminotomy procedures Spinal fusion surgery 25. Uvulopalatopharyngoplasty, including laser-assisted procedures 26. Ventricular assist devices* * All services deemed never effective are excluded from coverage. Aetna defines a service as never effective when it is not recognized according to
4 27. Special programs Beginning Right maternity program Including genetic testing, antenatal testing, perinatal consultations and counseling: BRCA genetic testing Cardiac rhythm implantable devices Precertification for all members with plans applicable to this precertification list unless services are emergent: Providers in all states where applicable, except metro New York and northern New Jersey, should contact MedSolutions to request preauthorization. You can reach MedSolutions: Providers in metro New York and northern New Jersey should contact CareCore National to request preauthorization. You can reach CareCore National: --Online at --By phone at for metro New York or for northern New Jersey Chiropractic precertification HMO-based plan members only --AZ through American Specialty Health (ASH) HMO-based plan and Group Medicare members only --CA through American Specialty Health (ASH) HMO-based, Aetna Health Network Option SM, Aetna Health Network Only SM and Medicare Advantage plan members only --Metro NY and the following upstate NY counties: Broome, Cayuga, Onondaga, Oswego, Tioga through American Chiropractic Network NJ through Triad For all members (with commercial and Medicare Advantage plans applicable to this precertification list): --CT; DC; DE; GA; Chicago, IL; MA; OH; PA; and VA through American Specialty Health (ASH) Infertility program Mental health or substance abuse services precertification See the member s ID card National Medical Excellence Program for all major organ transplant evaluations and transplants including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after high-dose chemotherapy Outpatient physical therapy (PT) and occupational therapy (OT) precertification Through OrthoNet Metro NY/NNJ For HMO-based and Medicare Advantage plan members only --CT For all members with plans applicable to this precertification list Through OptumHealth (ONLY OptumHealth/Aetna contracted providers should call this number for questions and service requests) --DC, NC, SC, VA For all members with plans applicable to this precertification list Pre-implantation genetic testing Pediatric Congenital Heart Surgery Program See the member s ID card to contact the precertification unit
5 Polysomnography (attended sleep studies) Providers in all states where applicable, except metro New York and northern New Jersey, should contact MedSolutions to request preauthorization. You can reach MedSolutions: Providers in metro New York and northern New Jersey should contact CareCore National to request preauthorization. You can reach CareCore National: --Online at --By phone at Radiation oncology AZ, FL and GA (Atlanta metropolitan area) Radiation oncology precertification through MedSolutions for all Aetna patients enrolled in HMO (including Medicare) and PPO-based benefits plans. You can reach MedSolutions: Metro NY/NNJ Radiation oncology precertification through CareCore National for HMO-based and Medicare Advantage plan members only. You can reach CareCore National: --By phone at for northern New Jersey members --By phone at for metro NY members Radiology imaging Through regional specific vendor (MedSolutions or CareCore National) where applicable for computed tomographic (CT) studies, coronary CT angiography, MRI/MRA, nuclear cardiology, PET scans, diagnostic left and right heart catheterizations and echo stress tests Additional assistance and information Electronic submission of precertification requests and inquiries is preferred. If you require assistance with precertification, please call our Aetna Voice Advantage line using the appropriate phone number indicated on the member s ID card and select the precertification option. For precertification of oral medications not indicated on this list, contact Aetna Pharmacy Management at Call for information on injectable medications not listed. Visit Clinical Policy Bulletins and our DocFind online provider directory. Precertification approvals are valid for six months in all states unless otherwise indicated at the time of precertification Aetna Inc V (12/13)
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