How Do I Get Prior Authorization For Aetna?

Prior Authorization in healthcare is a process used by insurance companies and healthcare providers to determine whether a specific medical treatment, procedure, medication, or service is medically necessary and covered by a patient's health insurance plan.

Aetna plays a significant role in the evolving landscape of American health insurance. Like many insurance providers, Aetna utilizes the process of prior authorization to ensure that the treatments and medications prescribed to its members are medically necessary, appropriate, and in line with the coverage stipulations of its various insurance plans.

Prior authorization (PA) is a process used by health insurance companies to determine if they will cover a prescribed procedure, service, or medication. The decision is based on medical necessity, appropriateness, and whether it is considered a covered benefit under the patient’s health plan. Before certain medical services or medications are provided to the patient, the healthcare provider must first obtain permission from the insurance company. If the provider doesn’t get this authorization, the insurance might not pay for the service or medication, leaving the patient responsible for the cost. The following booklets will help you understand how prior authorization works (Aetna):

Musculoskeletal prior authorization (PDF)

Prior Authorization Requirements

Prior authorization requirements are the source of much frustration for both patients and physicians. These policies force a physician to get prior approval from the insurer for a service or medication before it can be provided. This can cause delays in patient care and add to the administrative burden of practices. Prior authorization rules have been criticized for creating barriers to health care and increasing costs. In a 2020 survey, 30% of physicians reported that prior authorization requests caused patient care delays.

Medicare Advantage insurers require prior authorization for a variety of services, and the policies differ widely across plans. There is also substantial variation in how timely the initial determinations of these requests are made. In 2021, for example, Humana processed more than three times as many requests as UnitedHealthcare, but it denied nearly twice as many of them (Figure 1).

While some prior authorization denials are overturned after appeals, the number varies by plan. The highest rate of overturned denials was seen at Centene, which overturned 94 percent of its initial denials after an appeal. The lowest rate was at Kaiser Permanente, which overturned just under half of its initial denials after an appeal. This is largely because many insurers offer programs that waive prior authorization requirements for certain providers, such as risk-based contracts or “gold carding” programs.

Turnaround Time for Aetna Prior Authorization

Aetna has a number of different alerts in place to keep members updated on their prior authorization status. These alerts are designed to reduce the number of calls into their call centers and to help improve member experience. They also serve as a way to meet member disclosure requirements. Turnaround time for Aetna prior authorization can take up to 2 weeks.

Using these alerts can help doctors avoid the frustration of waiting for an insurance company to approve or deny a prior authorization. They can also help doctors avoid miscommunications that can lead to delays in care. This can happen when fax machines malfunction or when patients have difficulty getting someone on the phone to speak with.

Insurers may use prior authorization policies to limit access to certain health services, but critics say the requirements are often time-consuming and create unnecessary red tape for physicians and their patients. Physicians have also complained that the process can delay surgery and put patients at risk of harm, especially if they are unable to see their surgeon or take medication as prescribed.

Medicare Advantage insurers are not required to provide information about the turnaround times for their initial prior authorization determinations or appeal decisions. However, many of them do provide this information on their websites or through their claims processing systems. Additionally, they report this data to CMS on an annual basis.