[PDF] Directory - Aetna Medicare

For these purposes “generally accepted standardsof medical practice” means standards that are basedon credible scientific evidence published in peerreviewedmedical literature generally recognized by therelevant medical community, or otherwise consistentwith physician specialty society recommendations andthe views of physicians practicing in relevant clinicalareas and any other relevant factors.Clinical Policy BulletinsAetna's CPBs describe Aetna's policy determinationsof whether certain services or supplies are medicallynecessary or experimental or investigational, basedupon a review of currently available clinicalinformation. Clinical determinations in connectionwith individual coverage decisions are made on a casebycase basis consistent with applicable policies.Aetna's CPBs do not constitute medical advice.Treating providers are solely responsible for medicaladvice and for your treatment. You should discuss anyCPB related to your coverage or condition with yourtreating provider.While Aetna's CPBs are developed to assist inadministering plan benefits, they do not constitute adescription of plan benefits. Each benefit plan defineswhich services are covered, which are excluded, andwhich are subject to dollar caps or other limits. Youand your providers will need to consult the benefitplan to determine if there are any exclusions or otherbenefit limitations applicable to this service or supply.CPBs are regularly updated and are therefore subjectto change. Aetna's CPBs are available online atwww.aetna.com.PrecertificationPrecertification is the process of collecting informationprior to inpatient admissions and performance ofselected ambulatory procedures and services. Theprocess permits advance eligibility verification,determination of coverage, and communication withthe physician and/or you. It also allows Aetna tocoordinate your transition from the inpatient setting tothe next level of care (discharge planning), or toregister you for specialized programs like diseasemanagement, case management, or maternitymanagement programs.www.aetna.comIn some instances, precertification is used to informphysicians, members and other health care providersabout cost-effective programs and alternativetherapies and treatments.Certain healthcare services, such as hospitalization oroutpatient surgery, require precertification with Aetna.When you are to obtain services requiringprecertification from a participating provider, theprovider is responsible to precertify those services priorto treatment.If your plan covers out-of-network benefits andyou may self-refer for covered services, it is yourresponsibility to contact Aetna to precertifythose services which require precertification.Refer to your plan documents for specific information.Only medically necessary services are covered. Aservice or supply furnished by a particular provider ismedically necessary if Aetna determines that it isappropriate for the diagnosis, the care or thetreatment of the disease or injury involved.Note: If your enrolled in an Aetna Golden ChoicePlan, please refer to your plan documents forspecific information regarding precertification.Utilization Review/Patient ManagementAetna has developed a patient management programto assist in determining what health care services arecovered under the health plan and the extent of suchcoverage. The program assists you in receivingappropriate health care and maximizing coverage forthose health care services. You can avoid receiving anunexpected bill with a simple call to Aetna’s MemberServices team. You can find out if your preventive careservice, diagnostic test or other treatment is a coveredbenefit — before you receive care — just by callingthe toll-free number on your ID card. In certain cases,Aetna reviews your request to be sure the service orsupply is consistent with established guidelines and isincluded or a covered benefit under your plan. We callthis “utilization management review.”We follow specific rules to help us make your health atop concern:■ Aetna employees are not compensated based ondenials of coverage.VII