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Prior authorization: What you need to know
Getting approval for tests, procedures and more helps Aetna ensure that any care you receive is backed by the latest medical evidence. Learn more about prior authorization process below.
Some medical procedures, tests and prescriptions need prior authorization, which is sometimes called preapproval or precertification. This helps us make sure that your health care services are appropriate for your personal medical needs.
Here's how the prior authorization process works:
1. Visit your doctor
To get prior authorization, your doctor must first submit a request for a specific procedure, test or prescription. They will look at your overall health or any chronic conditions to make that decision. Then they’ll share the request with Aetna.
2. Check in with your doctor about the status of the requested prior authorizations
Once your doctor sends a request for prior authorization, Aetna reviews the request. During our review, we look at the most recent and highest quality medical research and guidelines. We update your care provider throughout the review process to keep them informed on the status, and come to a decision within 14 days. Your doctor can keep you updated on the status of your requested prior authorizations.
Need to find an in-network provider?
Visit AetnaMedicare.com/FindProvider or call Member Services at 1-833-570-6670 (TTY: 711) between 8 AM and 8 PM, 7 days a week.
Question of the month
"What do I need to get prior authorization for?”
Each Aetna plan has its own different rules on whether a referral or prior authorization is needed. To be sure, check Chapters 3 and 4 of your Evidence of Coverage (EOC) to see your plan’s rules for prior authorization.
Look for this note in your EOC: “Prior authorization may be required and is the responsibility of your provider.” You also need prior authorization for care that isn’t available through Aetna in-network providers.
Procedures, surgeries, supplies, medications and care that may require prior authorization include:
- Hip and knee replacements
- Radiology or imaging services
- Cardiac catheterizations and rhythm implants, to help your doctor assess your heart health
- Pain management
- Sleep studies
- Transplants
- Kidney dialysis
- Diabetic shoes and inserts
- Physical therapy, occupational therapy and speech therapy
- Home health aide services
- Medical equipment and supplies
- Some inpatient hospital care
For more help understanding what you need prior authorization for, call the Member Services number on your member ID card, 1-833-570-6670 (TTY: 711). We’re available between 8 AM and 8 PM, 7 days a week.
Are you happy with your Aetna plan?
If so, consider referring a friend or family member. They can call us at 1-844-947-3493 (TTY: 711) to see if they are eligible to enroll and to learn more about our plans. A licensed agent will answer their call.
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*FOR DETAILS ON NEWSWEEK AWARD: The 2023 Newsweek America's Best Customer Service rankings were identified from the results of an independent survey of more than 30,000 U.S. customers who have either made purchases, used services, or gathered information about products or services in the past three years. Customers evaluated several brands: in total over 200,000 evaluations were collected. The awarded brands each received on average 100 evaluations from customers. For more information visit https://www.newsweek.com/rankings/americas-best-customer-service-2023
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See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. Participating health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change.
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