Prior Authorizations

Primary care providers (PCP) or treating practitioner/providers are responsible for initiating and coordinating an enrollees request for authorization. However, specialists and other practitioners/providers may need to contact the Prior Authorization Department directly to obtain or confirm a prior authorization.

The requesting practitioner or provider is responsible for complying with Aetna Better Health’s prior authorization requirements, policies, and request procedures, and for obtaining an authorization number to facilitate reimbursement of claims. Aetna Better Health will not prohibit or otherwise restrict practitioner, acting within the lawful scope of practice, from advising, or advocating on behalf of, an individual who is a patient and enrollee of Aetna Better Health about the patient’s health status, medical care, or treatment options (including any alternative treatments that may be self-administered), including the provision of sufficient information to provide an opportunity for the patient to decide among all relevant treatment options; the risks, benefits, and consequences of treatment or non-treatment; or the opportunity for the individual to refuse treatment and to express preferences about future treatment decisions.

A prior authorization request must include the following:

  • Current, applicable codes may include:
    • Current Procedural Terminology (CPT)
    • International Classification of Diseases, 9th Edition (ICD-10 )
    • Centers for Medicare and Medicaid Services (CMS) Common Procedure Coding System (HCPCS) codes
  • National Drug Code (NDC)
  • Name, date of birth, sex, and identification number of the enrollee
  • Primary care provider or treating practitioner
  • Name, address, phone and fax number and signature, if applicable, of the referring practitioner or provider
  • Name, address, phone and fax number of the consulting practitioner or provider
  • Problem/diagnosis, including the ICD-10 code
  • Reason for the referral
  • Presentation of supporting objective clinical information, such as clinical notes, laboratory and imaging studies, and treatment dates, as applicable for the request

All clinical information must be submitted with the original request.