Sometimes, certain medical procedures, tests and prescriptions require prior authorization, or preapproval. This process helps make sure you get the care you need and that your treatments fit your health needs. Here’s what to know.

1. What is prior authorization?

Prior authorization is a process that helps us check if a treatment, test or medicine is safe and helpful for you. Sometimes, doctors need to get this approval before you can get certain treatments. This helps your health care provider make sure everything is right for you before starting.

2. How do you get prior authorization?

If you need prior authorization, talk with your primary care provider (PCP) or another health care professional. They can check on your overall health or any chronic conditions you may have. After looking over your needs, your provider will send a request to Aetna for the specific test, procedure or prescription.

3. How do I know if I need prior authorization?

Not sure whether you need preapproval or not? You can always ask your provider during an appointment. They can tell you if your plan requires it for the care they’re recommending. Your provider can help you through the process and make sure the prior authorization request is sent to Aetna.

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4. What happens after the prior authorization request is submitted?

Once Aetna gets the prior authorization request, the team reviews it to make sure it’s a good fit for you. They look at details such as:

• Health history
• Chronic conditions
• Past treatments

This helps us make sure the treatment or medication is safe and necessary.

Aetna will keep your provider updated on how the review is going.  If your prior authorization is approved, you should find out within 14 days. If it’s an urgent request, you may get the answer even sooner. Call Member Services to make sure your address, phone number and email address are correct so we can contact you.

5. What can you do while I wait?

You can still check on the status of your request. To learn more, call Member Services at 1-833-570-6670 (TTY:711) between 8 AM and 8 PM, 7 days a week.

6. What if your prior authorization request is denied?

Sometimes, a prior authorization request may not be approved right away. This could happen if there might be a safer or more effective option for your treatment or if more information is needed. Your provider can work with our team to look at other options or provide more details about why the treatment is important for your health.

If you have questions about why a request wasn’t approved, your provider can help answer questions and talk about next steps. You and your doctor might also have the option to appeal. This means asking us to look at the request again.

7. Why is prior authorization important?

Prior authorization may feel like an extra step. But it’s there to keep you safe. It helps make sure your health care is the right choice for your personal needs. If you ever have questions about prior authorization, call Member Services. They’re available to help guide you and make sure you understand each step of the process. Asking questions can help you feel more prepared and confident in getting the care you need.

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