Aetna will review the additional information along with the original submission as a new precertification request. When received more than 14 days from the date of the denial letter for services that have not yet started and the missing information is received within six (6) months of the date of the denial letter.When received within fourteen (14) calendar days of the letter of noncertification and peer to peer review has been completed.Aetna will review the additional information with the original request and make a determination based on all information received at that time. When received within fourteen (14) calendar days of the letter of noncertification and peer to peer review has not been completed for services that have not yet begun.If a request for authorization is not certified due to lack of clinical information required to make a medical necessity determination and no appeal has been submitted, we will review the request with additional information as follows: This will apply in cases where no information is received or if some clinical information is submitted but is inadequate to approve a request for authorization.Īdministrative denials for lack of clinical information

If the requested information is not received, an administrative denial for lack of clinical information will be made. We may require submission of clinical information to confirm medical necessity of the requested service, treatment, procedure, diagnostic service, therapy, ambulatory or inpatient service. We cover medically necessary treatment, procedures, therapies and diagnostic ambulatory and inpatient services. Alternatively, you can call Member Services to find the services requiring prior authorizations. You can find Aetna’s precertification list on our provider website. The Aetna ® PCP or network provider is responsible for obtaining this approval for covered in-network services. Sometimes we will pay for care only if we have given an approval before a member receives care.

Aetna timely filing limit 2021