Citi Benefits Handbook
Precertification Requirements for Aetna Plans
If you are enrolled in Aetna ChoicePlan 500 (CP500) or the High Deductible Health Plan (HDHP), you must call Aetna to precertify any inpatient surgery or hospitalization and certain outpatient diagnostic/surgical procedures. Scheduled inpatient services and non-emergency outpatient procedures must be precertified at least 14 days in advance. Aetna must be notified of emergency admissions within 48 hours of the admission.
You are not required to notify Aetna of emergency hospitalization or other emergency services occurring outside the United States.
For inpatient confinement, you must call Aetna for precertification at least 14 days prior to the scheduled admission date. An admission date may not have been set when the confinement was planned. You must call Aetna again as soon as the admission date is set.
You must obtain precertification for:
- A scheduled hospital admission;
- A scheduled admission to a skilled-nursing hospice care or rehabilitation facility;
- Home health care, including psychiatric home care services;
- Private-duty nursing;
- Outpatient hospice care;
- Amytal interview (used with medical procedures as part of testing for prediction of memory dysfunction that may be a result of brain surgery);
- Psychological testing;
- ABA — applied behavior analysis;
- Electroconvulsive therapy;
- Neuropsychological testing;
- Bariatric services;
- Cardiovascular services;
- Musculoskeletal services; and
- Gender reassignment surgery.
In case of an unscheduled or emergency admission, you or your doctor must call Aetna within 48 hours after the admission.
Mental Health/Substance Abuse
You must call Aetna for precertification before you obtain covered inpatient mental health and/or substance abuse treatment, including stays in a residential treatment facility or a partial hospitalization program, outpatient detoxification, intensive outpatient programs or psychiatric home care services.
You must notify Aetna before the scheduled date of any of the following:
See organ/tissue transplants in "Covered Services and Supplies" for information about precertification requirements. Aetna will then complete the utilization review. You, the physician and the facility will receive a letter confirming the results of the utilization review.
Pregnancy is subject to the following notification time periods:
- Aetna should be notified during the first trimester (12 weeks) of pregnancy. This early notification makes it possible for the mother to participate in a prenatal program;
- You must notify the plan to certify inpatient confinement for delivery of a child. This is to certify a length of stay that exceeds:
- For inpatient care (for either the mother or child) that continues beyond the 48/96-hour limits stated above, Aetna must be notified before the end of these time periods; and
- Non-emergency inpatient confinement during pregnancy but before the admission for delivery requires notification as a scheduled confinement.
If you or your physician does not agree with Aetna's determination, you may appeal the decision. For information about the claims appeal process, see "Claims and Appeals for Aetna Medical Plans."