Does Aetna Medicare Require Prior Authorization?

Are you wondering, “does Aetna Medicare require prior authorization” for services or medications? The short answer is yes; Aetna Medicare often requires prior authorization to confirm that a service or medication is medically necessary and covered under your plan.

Understanding this requirement is crucial for accessing care and avoiding unnecessary expenses. This article will provide you with an overview of prior authorization with Aetna Medicare in 2025, explain which services typically require it, and guide you through the process should your request be denied.

 

Key Takeaways

 

 

  • Denied prior authorization requests can be appealed, and understanding the reasons for denial is crucial, which usually pertains to a lack of medical necessity or insufficient clinical evidence.

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Understanding Prior Authorization with Aetna Medicare

 

Does Aetna Medicare Require Prior Authorization?, Understanding Prior Authorization with Aetna Medicare

 

Prior authorization in medical insurance is the process where patients must obtain approval for a health care service or medication before it is provided. This is to ensure that the care is medically necessary and covered under the plan.

Recent changes in Aetna’s prior authorization policies have had a direct impact on Medicare recipients’ ability to access care. Some of these changes include:

  • The elimination of the requirement for physical therapy in five states

 

  • The addition of new medications to the prior authorization list

 

  • The implementation of stricter criteria for certain procedures

 

These changes have caused delays and barriers to care for many Medicare recipients. It is important for patients to be aware of these changes and advocate for their own health care needs.

 

What is Prior Authorization?

A process called prior authorization is a procedural requirement in which a healthcare provider must secure approval from the Aetna Medicare plan prior to the coverage of a service or treatment for the patient.

This approval is used to validate the medical necessity and adherence to Aetna’s coverage criteria for certain services or treatments.

 

How Does Prior Authorization Work at Aetna?

To obtain prior authorization with Aetna Medicare, your physician must submit a request for the required procedure, test, or prescription. Aetna then assesses the request, typically providing a decision within 14 days.

Both you and your physician will be notified of the decision, ensuring better health outcomes.

 

Services Typically Requiring Prior Authorization

Certain services that often require prior authorization with Aetna Medicare include:

  • MRIs or CT scans

 

  • Orthognathic surgery procedures

 

  • Bone grafts

 

  • Hip and knee replacements

 

  • Specific prescription drugs

 

This ensures that patients receive the right care according to their plan coverage.

 

Navigating Your Health Plan: Prior Authorization Details

 

Does Aetna Medicare Require Prior Authorization?, Navigating Your Health Plan: Prior Authorization Details

 

Healthcare providers are key participants in the Aetna Medicare prior authorization process. They have the following responsibilities:

  • Review the criteria for medical necessity

 

  • Secure Aetna’s approval for certain procedures and services

 

  • Provide comprehensive details about the procedure, test, or prescription that requires prior approval

 

  • Submit a prior authorization request on behalf of the patient

 

Finding Out If You Need Prior Authorization

The Evidence of Coverage (EOC) in Aetna Medicare serves to outline the plan’s regulations, including the process of prior authorization. Individuals can ascertain whether a particular service needs prior authorization by referencing the EOC or by contacting Aetna Medicare or their primary care provider (PCP).

 

The Role of Your Healthcare Provider in Prior Authorization

Healthcare providers can submit prior authorization requests to Aetna on behalf of patients through several methods, such as electronic data interchange (EDI), the Aetna secure provider website, or by phone.

However, without obtaining prior authorization when needed, the insurer may refuse to cover the service or treatment, leading to financial loss and disruptions in patient care timelines.

Steps to Take if Prior Authorization is Not Granted

 

Does Aetna Medicare Require Prior Authorization?, Steps to Take if Prior Authorization is Not Granted

 

If a prior authorization request is denied, it is typically due to factors like insufficient clinical documentation or failure to meet the criteria for medical necessity. In these situations, understanding the denial reasons and examining alternative choices is important.

 

Understanding the Reasons Behind a Denial

The main factors contributing to Aetna Medicare’s prior authorization denials include:

  • Requests for experimental or investigational services

 

  • Services without proven effectiveness

 

  • Cases where there is not enough clinical evidence to support the request

 

Your Options After a Denial

If prior authorization is denied, you can appeal the decision by contacting Aetna at 1-800-282-5366 (TTY: 711) to learn about the appeals process.

The appeal process with Aetna Medicare may take up to 180 days for specific issues, 30 days if filed before the service is rendered, and 72 hours for expedited decisions.

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Member Resources for Prior Authorization

 

Does Aetna Medicare Require Prior Authorization?, Member Resources for Prior Authorization

 

Aetna Medicare provides educational resources via Member Services to help members grasp the concept of prior authorization. They also provide helpful guidance on their website to clarify the prior authorization process.

 

Contact Information for Support

If you need assistance with prior authorization, you can contact the Member Services number on your member ID card at 1-833-570-6670 (TTY: 711) for immediate help or 1-844-362-0934 (TTY: 711) for additional support.

Aetna Medicare customer service can also be reached at PO Box 7083, and their service center is operational 24/7, seven days a week.

 

Online Tools and Documents

Aetna offers several online tools for prior authorization, such as a search tool to determine if precertification is necessary. Prior authorization forms can be accessed online through the Aetna website.

Members can conveniently track the status of their request and submit a Letter of Authorization by logging in to their member website using their d card.

Cost Implications of Prior Authorization

 

Does Aetna Medicare Require Prior Authorization?, Cost Implications of Prior Authorization

 

The average out-of-pocket cost for services that require prior authorization with Aetna Medicare may vary. For out-of-network visits, it is approximately $425, which includes the cost share.

Prior authorization is key to managing healthcare service costs by preventing the performance of unnecessary or inexpensive covered services.

 

Impact on Out-of-Pocket Costs

A significant number of individuals undergoing prior authorization have indicated an increase in out-of-pocket expenses for their care.

However, prior authorization for Aetna Medicare members serves to guarantee the safety, effectiveness, and medical appropriateness of treatments, thereby averting unnecessary expenses.

 

Avoiding Unexpected Medical Bills

One of the key benefits of comprehending your health insurance plan is evading unforeseen medical expenses.

Adequate communication and regular check-ins with Aetna Medicare prior authorization can help to ensure that the care received is supported by the latest medical evidence, reducing the occurrence of unexpected bills.

Ensuring Your Treatment is Medically Necessary

Aetna Medicare’s definition of medical necessity is outlined in their Medical Clinical Policy Bulletins (CPBs). These bulletins offer detailed information on services and procedures categorized as medically necessary, cosmetic, or experimental and unproven.

Adequate documentation, including medical notes, test results, and treatment plans, plays a crucial role in ensuring the completeness and accessibility of essential information, thereby enhancing the likelihood of a successful approval for prior authorization.

 

Criteria for Medical Necessity

Aetna evaluates the appropriateness of procedures, tests, and prescriptions for individuals by requiring prior authorization to ensure they are suitable. Medical professionals at Aetna are responsible for reviewing and determining the medical necessity for a treatment.

 

The Importance of Documentation

Documentation carries significant weight in the prior authorization process. It provides necessary information to support approval and lessen denials.

To ensure the efficient organization and submission of plan documents for Aetna Medicare’s Prior Authorization process, it is recommended to adhere to the prior authorization guidelines and precertification lists offered by Aetna.

Accessing Prescription Drugs with Aetna Medicare

 

Does Aetna Medicare Require Prior Authorization?, Accessing Prescription Drugs with Aetna Medicare

 

Aetna Medicare prescription drug coverage (Part D) is provided by private insurance companies. Approved drugs are available at the cost specified in higher tiers, such as tier 4 or 5.

If a patient proceeds with a service that necessitates prior authorization without obtaining approval, they may encounter denied coverage and subsequently incur out-of-pocket expenses.

If Aetna Medicare’s authorization is not obtained, the patient may be responsible for the entire service cost.

 

Prescription Drug Coverage and Prior Authorization

To obtain prescription drug coverage with Aetna Medicare, individuals have the option to enroll in a stand-alone Medicare Part D plan or select an Aetna Medicare Advantage plan that offers combined medical and pharmacy benefits. Some medications may necessitate prior authorization from the plan before they can be dispensed.

 

Process for Obtaining Drug Approvals

The process to obtain drug approvals through Aetna Medicare involves several steps. First, a stand-alone Medicare Part D plan or a Medicare Advantage plan that includes prescription coverage may need to be purchased.

Second, certain drugs, procedures, tests, and prescriptions may necessitate prior approval. This can be submitted by a doctor on behalf of the patient.

Summary

Prior authorization can seem like a complex process, but with the right information and resources, it can be navigated with ease. Armed with the knowledge of understanding the role of prior authorization in your Aetna Medicare plan, the steps to take if prior authorization is not granted, and the cost implications, you can be better prepared to handle your healthcare needs.

 

Frequently Asked Questions

 

  Does Medicare require prior authorizations?

In general, Medicare Part A or Part B rarely require prior authorization for many pre-approved services, but there may be exceptions for certain items like prosthetics and durable hospital equipment.

Therefore, it is important to understand your coverage and specific situation to determine if prior authorization is required for certain services.

 

  Is Aetna Medicare PPO the same as Medicare?

Aetna Medicare PPO provides the same benefits as Original Medicare and more, as it includes all the benefits and services of Parts A and B.

It is a Medicare Advantage plan offered by a private insurance company.

 

  Does Aetna Medicare require prior authorization for cataract surgery?

No, Aetna Medicare does not require prior authorization for most cataract surgeries. This policy change was announced on June 30.

 

→  Does Aetna use eviCore healthcare?

Yes, Aetna has released a new policy requiring healthcare professionals to work with eviCore for pre-authorizing peripheral services, effective September 1, 2023.

 

 What is prior authorization?

Prior authorization is a requirement for healthcare providers to obtain approval from the insurance plan before providing certain services or treatments to patients. This helps ensure coverage and assists in managing healthcare costs.

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Speak with a licensed insurance agent

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.