MHPAEA summary: precertification, NQTLs, and parity processes
Summarizes Aetna's Mental Health Parity and Addiction Equity Act (MHPAEA) analysis and describes prior authorization (precertification) processes, factors, sources, and timelines affecting mental health/substance use disorder and medical/surgical benefits; intended for members, providers, and regulators (Maryland report summary).
Policy Summary
PayerAetna
PolicyMHPAEA summary: precertification, NQTLs, and parity processes
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionProviders must obtain precertification for services listed on Aetna's precertification lists; in-network providers are responsible for securing approval to avoid member billing.
No material clinical or coverage changes in this revision.
2 working daysMD timeliness
180 daysApproval validity
14 daysNon-emergency lead time
5 vs ~34MH/SUD vs M/S NPL count
34%MH/SUD non-formulary approval
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Coverage Criteria and NQTL Findings
Prior authorization development and decision criteria
Factors, sources, and evidentiary standards used to develop prior authorization lists, administration processes, and approval/denial criteria.
ALL of the following
Primary evidentiary sources include well-conducted clinical trials or cohort studies published in peer-reviewed literature; Aetna Clinical Policy Bulletins (CPBs); MCG care guidelines; NCCN treatment guidelines; and specialty-specific criteria such as ASAM, LOCUS/CALOCUS/CASII.
Drug-specific sources include FDA labeling, peer-reviewed literature, therapeutic class reviews, drug monographs, utilization trend reports, and consideration of drug pipeline and safety data.
ALL of the following
Clinical appropriateness in terms of type, frequency, extent, site, place of service, and duration.
Patient-specific factors: age, comorbidities, complications, treatment response/progress, need for skilled care, psychosocial situation, and treatment setting (including home environment).
Cost-effectiveness considerations where multiple clinically equivalent treatments exist (preferred placement of less costly equally efficacious options).
State and federal law and NCQA utilization management standards guide timelines and processes.
ALL of the following
Selection of services subject to prior authorization is governed by written lists (National Precertification List/Aetna Participating Provider Precertification List) and applies consistently across M/S and MH/SUD classifications.
Clinical review and medical necessity determinations are made by clinicians using the same Clinical Policy Council, CPBs, and third-party guidelines; application and governance do not differ by MH/SUD vs M/S.
Committees (FRC and P&T) and PBM pharmacists review formulary and utilization management decisions using the same monographs, therapeutic class reviews, meeting processes, and voting procedures regardless of drug category.
ALL of the following
Timeliness standards follow NCQA and applicable state rules (e.g., Maryland requirement that non-urgent precertification requests be completed within 2 working days after receipt of needed information).
Operational timeframes for notification include non-emergency precertification lead time (call at least 14 days before scheduled admission), emergency admission notification within 48 hours, and approval validity periods (approvals valid for 180 days).
Expedited/medical exception processes are available for precertification, step therapy, quantity limits, and non-covered drugs with expedited decisions within 24 hours when applicable.
ALL of the following
Internal Quality Reviews (IQR) and Inter-Rater Reliability (IRR) audits are performed (2023 audits cited) to assess consistent application of criteria and comparability of MH/SUD and M/S determinations.
Operational data review includes analysis of approval/denial rates and non-formulary request volumes to confirm NQTLs are not applied more stringently to MH/SUD benefits.
Medical necessity and prior authorization criteria (MH/SUD and M/S)
Medical necessity determinations for both MH/SUD and M/S are made using the same Certificate of Coverage definition, factors, sources, and processes.
ALL of the following
Clinicians apply the same written medical necessity definition from the Certificate of Coverage for both MH/SUD and M/S.
Guidelines and tools used include Aetna Clinical Policy Bulletins (CPBs), MCG, NCCN, ASAM Criteria, LOCUS/CALOCUS/CASII, and ABA guidance as applicable to the condition or population.
ALL of the following
Reviews consider clinical appropriateness (type, frequency, extent, site, duration), patient age, comorbidities, complications, treatment progress, need for skilled care, psychosocial circumstances, and safety concerns.
ALL of the following
Prescription drug NQTL and formulary criteria conclusions
Findings and conclusions regarding application of prescription drug NQTLs and formulary design to MH/SUD versus MED/SURG drugs.
ALL of the following
Prior authorization and formulary NQTLs are not applied more stringently to MH/SUD drugs than to MED/SURG drugs, both as written and in operation.
Formulary design and tier placement use the same factors, evidentiary standards, committee processes, and voting procedures for MH/SUD and MED/SURG drugs.
ALL of the following
Testing showed prior authorization applied to a lower percentage of MH drugs and to zero percent of SUD drugs compared to MED/SURG; analyses at the drug-class level confirmed factors and sources are applied consistently.
PBM pharmacists reviewed non-formulary request volumes and approval rates: of 363 non-formulary requests, 130 were MH/SUD; approval rate for MH/SUD requests was 34% versus 27% for MED/SURG (Advanced Control sample), demonstrating no more stringent treatment of MH/SUD.
Formulary Design NQTL Parity Conclusion
Formulary design and tier placement NQTL — written policies and operational application.
ALL of the following
No separate policies or procedures exist for MH/SUD drug formulary design versus MED/SURG; the same processes, monographs, therapeutic class reviews, and evidentiary standards are used for tier assignment decisions.
Personnel and committee credentials are consistent across drug categories; meetings consider drugs together without regard to whether they treat MH/SUD or MED/SURG conditions.
ALL of the following
In-operation analyses and testing of tiers show factors and sources are applied consistently across MH/SUD and MED/SURG drugs; non-preferred tier placements (tiers 3 and 5) are not more stringent for MH/SUD drugs and therapeutic alternatives exist in preferred tiers.
PBM and formulary reviews support that tier placement decisions reflect drug-specific clinical evidence, cost-effectiveness, and availability of alternatives rather than the therapeutic area alone.
Provider Reimbursement NQTL Parity Conclusion
Provider reimbursement NQTL — participating and non-participating providers.
ALL of the following
Participating provider reimbursement is implemented via the negotiated charge — the amount a network provider has agreed to accept or that Aetna has agreed to pay; the factors, strategy, processes, and evidentiary standards used to establish these rates are the same for MH/SUD and M/S providers.
ALL of the following
Non-participating provider reimbursement is implemented via the allowable amount, which is the portion of an out-of-network provider's charge eligible for coverage and is determined the same way for MH/SUD and M/S claims (e.g., specified percentile of prevailing charges or percentage of Medicare rates as applicable).
For HSCRC-regulated hospitals, rates set by HSCRC are used; for other claims, methodologies comply with Maryland law and applicable federal rules (e.g., median contracted rate calculations for surprise billing).
ALL of the following
Surprise Billing / Allowable Amounts
Payment methodology and surprise billing rules.
ALL of the following
Negotiated charge: the amount a network provider has agreed to accept or that Aetna has agreed to pay; for surprise-billing calculations, the median contracted rate is used.
Allowable amount: the portion of an out-of-network provider's charge eligible for coverage; members are responsible for charges above this amount and calculations depend on geographic area and plan-specific methods.
ALL of the following
An out-of-network provider cannot balance bill for emergency services, certain non-emergency services at in-network facilities (unless appropriate notice and consent obtained), and out-of-network air ambulance services; surprise-bill payments are determined using the median contracted rate for similar providers in the market and subject to federal regulation adjustments.
Provider Shortage Strategies
Strategies to address provider shortages and network adequacy.
ALL of the following
Aetna maintains sufficient numbers and types of M/S and MH/SUD providers and monitors network adequacy through required annual Maryland filings and internal analyses; geographic availability and numeric provider standards are defined in policy consistent with COMAR.
Appointment access timeframes required by Maryland regulation apply to both M/S and MH/SUD (urgent care ≤72 hours; routine primary care ≤15 days; preventive/nonurgent specialty ≤30 days; nonurgent behavioral health/SUD ≤10 days).
ALL of the following
In operation, Aetna monitors wait times and provider-to-member ratios and takes interventions to increase provider availability and accessibility when needed; actions for MH/SUD providers improved access from 2022 to 2023.
Open panels and provider recruitment activities are used comparably across M/S and MH/SUD to address shortages.
Access, adequacy, and directory criteria
Standards and practices governing member access to in-network M/S and MH/SUD services in Maryland.
ALL of the following
Providers must meet Maryland appointment access timeframes: urgent care within 72 hours; routine primary care within 15 calendar days; preventive/nonurgent specialty within 30 calendar days; nonurgent behavioral health/SUD within 10 calendar days.
These standards derive from COMAR and are applied equally to M/S and MH/SUD provider types.
ALL of the following
Aetna conducts Maryland annual Network Adequacy filings and internal monitoring of availability and accessibility; analyses show networks for both M/S and MH/SUD met or exceeded minimum standards and median wait times were below standards.
Interventions and recruitment efforts are applied comparably across M/S and MH/SUD and have demonstrable improvements for MH/SUD access from 2022 to 2023.
Directory parity criteria
Aetna's assessment of parity between MH/SUD and M/S in directory practices.
ALL of the following
Aetna applies the same inclusion criteria for provider directories for both M/S and MH/SUD — all contracted providers are listed and required legal information is included.
Directory content includes MH/SUD-specific focus areas and service-level details (e.g., diagnoses, specialty focus) to aid member searchability; these additional fields are applied equally and do not restrict MH/SUD listings.
ALL of the following
Operational features such as free-text search, categorical navigation (including a dedicated Mental Health category), and filterable focus areas provide equal or better search capability for MH/SUD compared to M/S services.
ALL of the following
Coding, Codes Tables and Timelines
Medical-plan administered drugsmixedCovered
Certain prescription drugs are covered under the medical plan when administered by a provider and may require precertification.
Inpatient determination guidancemixed
Place of service/inpatient status determined using National Uniform Billing Committee guidance for facility billing
Formulary tiers and coverage levelsmixedCovered
Drugs categorized by tier: preferred generic, preferred brand, non-preferred brand and generic, preferred specialty, non-preferred specialty; coverage based on the drug guide with medical exception process.
Precertification approval duration
Precertification approval durationApprovals (precertification) are valid for 180 days as long as the member remains enrolled in the plan.
Non-emergency precertification lead timeCall at least 14 days before scheduled non-emergency admission or outpatient non-emergency medical services.
Emergency admission notificationCall within 48 hours or as soon as reasonably possible after admission for emergency admissions.
Number of MH/SUD services on NPL
Number of MH/SUD services on National Precertification List (NPL)There are 5 MH/SUD services included on the NPL.
Comparison to M/S categories
Provider Responsibilities, Precertification and Appeals
Note
Identification of benefits requiring prior authorization
Please see Aetna's precertification lists (Aetna Participating Provider Precertification List, Aetna Behavioral Health Precertification List — together the National Precertification List (NPL)) for identification of medical/surgical and mental health/substance use disorder benefits that require prior authorization.
Prior Authorization
Precertification responsibilities and timelines
You need pre-approval (precertification) from Aetna for some covered services. Network providers are responsible for obtaining any necessary precertification before care is provided. For out-of-network care, the member is responsible for obtaining any required precertification. Timeframes and timelines for requesting precertification vary by urgency — see timelines block below. Emergency services do not require precertification, but notification is required as soon as reasonably possible.
Network (in‑network) providers must obtain precertification for services on the Aetna Participating Provider Precertification List and Aetna Behavioral Health Precertification List (the NPL). Network providers cannot bill members for services solely because they failed to obtain precertification, though if a request is denied and the member elects care, the member may be financially responsible.
Definitions and Reference Terms
Non-Quantitative Treatment Limitations (NQTLs)
DefinitionNon-Quantitative Treatment Limitations (NQTLs) are limits on benefits other than numerical limits (for example, prior authorization requirements) that affect the scope or duration of treatment.
ExamplesNQTLs include management techniques such as prior authorization, step therapy, and other non-numeric limits on care.
Parity relevanceUnder MHPAEA, NQTLs for MH/SUD cannot be more restrictive than those for medical/surgical benefits.
Precertification / Prior authorization
Definition and alternate namesPrecertification (also called pre-approval or prior authorization) is the process of obtaining Aetna approval before receiving certain covered services.
Applicability
Policy Summary
PayerAetna
PolicyMHPAEA summary: precertification, NQTLs, and parity processes
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionProviders must obtain precertification for services listed on Aetna's precertification lists; in-network providers are responsible for securing approval to avoid member billing.
Aetna applies the same processes, factors, and evidentiary standards to determine medical necessity for MH/SUD and M/S; IQR and IRR audits in 2023 show comparable or slightly higher accuracy for MH/SUD determinations and fewer denials for MH/SUD in operation.
ALL of the following
Applies to
In-network inpatient services
In-network outpatient (all other) services
Prescription benefit classifications where drugs require prior authorization
Out-of-network outpatient MH/SUD precertification is not required for Maryland-sitused policies as of 01/01/2023; in-network participating providers are responsible for obtaining precertification for listed services.
ALL of the following
If precertification is denied, Aetna explains reasons and provides instructions for review (appeals/complaints).
Medical exception and expedited request procedures are available to providers/members, including submission via Availity, phone, fax, or mail; expedited decisions made within 24 hours when criteria met.
ALL of the following
FRC and P&T committees review MH/SUD and MED/SURG drugs together using the same monographs, therapeutic class reviews, and meeting processes; membership expertise does not differ based on drug category.
Formulary decisions consider clinical evidence, FDA labeling, cost-effectiveness, therapeutic alternatives, and utilization data in the same manner for all drugs.
ALL of the following
Members may request medical exceptions to prior authorization, step therapy, or quantity limits; if approved, medically necessary outpatient prescription drugs are covered per plan design and member cost-sharing applies after deductible.
Expedited decisions for medical exceptions are available (24-hour expedited timeframe).
ALL of the following
Formulary and tier decisions are made through established committees (P&T, FRC) relying on drug monographs, therapeutic class reviews, and consistent voting processes; review cadence and committee governance apply equally to MH/SUD and MED/SURG drugs.
Aetna applies the same factors, strategy, processes and evidentiary standards to determine reimbursement for MH/SUD and M/S facility-based providers; methods for determining allowable amount and negotiated charge do not differ by benefit category.
Any cost share paid will apply toward in-network deductible and out-of-pocket maximum; members may request external review regarding surprise-billing applicability.
ALL of the following
For claims other than HMO, Aetna complies with Maryland statutes (e.g., HB 959) regarding reimbursement and non-imposition of greater cost-sharing for emergency services; for surprise bills, qualifying payment amount methodology follows federal rules (45 C.F.R. §149.140(c)).
Factors used in developing payment limitations include Maryland law, HSCRC rates, and federal law; HSCRC rates are applied for regulated hospitals and loaded into claim systems.
ALL of the following
Methods and definitions for negotiated charge and allowable amount are applied the same to MH/SUD and M/S providers; evidence supports comparable application in operation.
ALL of the following
Network availability: geographic distribution of appropriate practitioner types and counts; network accessibility: members' ability to receive timely care (schedule appointments).
Minimum availability standards are applied for specified inpatient and outpatient facility types for both M/S and MH/SUD (e.g., inpatient psychiatric facilities, SUD residential treatment, outpatient MH clinics).
ALL of the following
Maryland Network Adequacy filings and operational analyses show median appointment waiting times below standards for both M/S and MH/SUD, with non-urgent MH/SUD care available sooner than non-urgent M/S care in the reviewed period.
ALL of the following
Directory and online tools are used to support access and recruitment by making provider information searchable and by supporting provider outreach and verification processes.
Operational detail: specific numeric standards and monitoring cadence referenced in Maryland filings and COMAR requirements.
ALL of the following
A single provider directory (online and paper) is maintained for both M/S and MH/SUD providers; the online directory is updated six days/week and the paper directory is updated quarterly; the directory includes specialties, facility types, language accessibility, and disability access information.
Providers may notify Aetna of changes via a provider portal or online form; directory audits are conducted quarterly to verify accuracy.
ALL of the following
The online directory is publicly accessible without an account and includes search/filter features (including MH-specific focus areas and facility types) to help members find appropriate providers; directory entries include information helpful for MH/SUD selection such as focus areas and services offered.
Operational practice: targeted proactive directory reviews and outreach calls are used to verify providers without activity at listed service locations and remove inactive locations.
Maintenance procedures (quarterly provider prompts to verify information), targeted proactive directory quality reviews, outreach calls, and periodic directory audits are applied comparably to MH/SUD and M/S providers.
2023 directory audit results showed fewer MH/SUD inaccuracies compared to M/S and similar or higher proportions of MH/SUD providers accepting new patients, supporting operational parity.
ALL of the following
Processes and strategies for directory design and maintenance are not applied more stringently to MH/SUD than to M/S services; members can search for and locate participating MH/SUD providers at least as easily as M/S providers.
The directory is available in Spanish and provides accessibility information and a web link under each entry to report incorrect provider information.
Approximately 34 medical/surgical service categories are subject to precertification (comparison context).
Change frequencyNo new MH/SUD services have been added to the NPL in the past 6 years.
Expedited decision timeframe
Expedited decision timeframe for medical exceptionsExpedited coverage decisions are made within 24 hours.
How to request expedited reviewMembers or prescribers can request medical exceptions and ask for expedited review via Availity, phone, fax, or mail to the Medical Exception unit.
Outcome communicationAetna will contact the member or prescriber with the decision following expedited review.
Appointment access timeframes
Urgent care appointment timeframeUrgent care appointments (including medical, behavioral health and SUD) must be available within 72 hours.
Routine primary care timeframeRoutine primary care appointments must be available within 15 calendar days.
Preventive/nonurgent specialty timeframePreventive visits and nonurgent specialty care must be available within 30 calendar days.
Nonurgent behavioral health/SUD timeframeNonurgent behavioral health and substance use disorder services must be available within 10 calendar days.
Audit sampling frequency
Audit sampling frequencyDirectory accuracy audits include a periodic sample of practitioners selected and audited on a quarterly basis by the DVQ Outreach Team.
Audit scope and actionsAudits update contact information, remove providers not practicing at listed locations, and analyze root causes to improve data quality.
Parity in auditsDirectory accuracy audits apply equally to MH/SUD and M/S providers and facilities, with results monitored in aggregate.
Members (out‑of‑network) are responsible for obtaining precertification for services on the Member Precertification List (MPL) included in the certificate of coverage. Failure to precertify may reduce benefits or result in member liability; such unpaid amounts may not count toward the plan deductible or out‑of‑pocket maximum.
To obtain precertification contact Aetna 24/7; representatives are available to accept requests from members, providers or facilities.
Prior Authorization
Services requiring precertification
Precertification is required for all inpatient admissions (medical/surgical and MH/SUD) except where specifically excluded (for example inpatient maternity and hospice). Precertification is also required for certain outpatient services and supplies as listed on the NPL and MPL. Examples include inpatient stays (hospital, rehabilitation, residential treatment for MH/SUD, hospice), and outpatient services such as complex imaging, comprehensive infertility services, cosmetic/reconstructive surgery, certain injectables and infusion drugs, kidney dialysis, many outpatient surgeries (e.g., outpatient back/knee/wrist surgery), sleep studies, non‑emergency air transport, and gene‑based, cellular and other innovative therapies (GCIT). Certain prescription drugs administered in a medical setting also require precertification.
For in‑network benefits the participating provider is responsible for seeking precertification for services listed on the Aetna Participating Provider Precertification List and Aetna Behavioral Health Precertification List (the National Precertification List). There is no penalty to the member if precertification is not obtained by a participating provider; the network provider may not balance‑bill the member for failing to request precertification.
Prior Authorization
Precertification responsibility (out-of-network)
For out‑of‑network benefits, members are responsible for seeking precertification of services that appear on the Member Precertification List (MPL) included with the certificate of coverage. The MPL describes the consequences of failing to obtain precertification. Note: as of 01/01/2023, out‑of‑network outpatient MH/SUD services do not require precertification for members covered under Maryland‑sitused policies.
Prior Authorization
Inpatient precertification and urgency
All inpatient admissions (both medical/surgical and MH/SUD) are subject to precertification except for the limited exceptions noted (e.g., inpatient maternity and hospice). Aetna determines inpatient status using place of service guidance (National Uniform Billing Committee) and applicable law (including the Newborns' and Mothers Health Protection Act). For inpatient stays Aetna will communicate the precertified length of stay; any recommended extensions must be precertified and called in no later than the final authorized day.
Inpatient precertification applies equally to M/S and MH/SUD admissions.
For inpatient admissions, the facility, physician, or member must notify Aetna per the timelines; if additional days are recommended they must be submitted for review before the end of the authorized stay.
Note
Timeliness standards and Maryland requirement
Timelines for precertification requests depend on urgency. Non‑emergency outpatient and scheduled admissions: call at least 14 days before the scheduled date. Urgent admissions: call before scheduled admission (treated as urgent when due to onset/change in illness or injury). Emergency admissions: notify Aetna within 48 hours or as soon as reasonably possible after admission. Approvals are generally valid for 180 days while the member remains enrolled. Maryland law requires non‑urgent precertification requests to be completed within 2 working days after receipt of information needed for review. Aetna applies NCQA timeliness standards and treats all inpatient MH/SUD admissions as urgent for timeline purposes.
Non‑emergency scheduled care: call at least 14 days prior.
Urgent admission: call before scheduled admission; treated with expedited/urgent timeline.
Emergency admission: call within 48 hours or as soon as reasonably possible.
Approvals typically valid for 180 days while enrolled.
Maryland requirement: non‑urgent requests completed within 2 working days after receipt of needed information.
Prior Authorization
Medical exception and expedited request procedures
If a provider or member needs a medical exception for precertification, step therapy, quantity limits, or for a non‑formulary drug, requests can be submitted and may be expedited. Expedited coverage decisions are made within 24 hours. Providers may submit medical exception requests via the secure provider portal (Availity), by phone, fax, or mail to the Aetna Pharmacy Precertification/Medical Exception units. See Aetna contact resources for specific phone/fax numbers and addresses.
Expedited medical exception decisions: within 24 hours.
Submission methods: Availity provider website, phone, fax, or mail to the Medical Exception unit.
Aetna reviewed non‑formulary coverage request data by formulary. For the Advanced Control formulary there were 363 total non‑formulary requests, 130 of which were for MH/SUD drugs; MH/SUD non‑formulary requests had a 34% approval rate versus 27% for medical/surgical drugs.
For the Standard Opt Out formulary there were 6 total non‑formulary requests with 1 MH/SUD drug request (0% approval rate). For Med/Surg drugs on that formulary there was a 60% approval rate (3 of 5 requests).
Note
Non‑formulary coverage request review (Exchange)
For the Exchange formulary there were 733 total non‑formulary requests, 183 of which were MH/SUD drug requests. MH/SUD non‑formulary requests had a 28% approval rate versus 19% for medical/surgical non‑formulary drugs.
Prior Authorization
Network provider not reasonably available
If an appropriate network provider is not reasonably available without undue delay, travel, or lacks the necessary training/expertise, members may obtain services from an out‑of‑network provider with prior approval from Aetna. Members must request approval before receiving such care; contact Aetna for assistance.
Network provider not reasonably available allows prior approval for out‑of‑network care when lack of reasonable access would otherwise delay or prevent needed care.
Member must obtain prior approval before receiving out‑of‑network services under this exception.
Documentation Required
Provider directory verification and quality review
Participating providers are required to notify Aetna of changes to their practice information. Both medical/surgical and MH/SUD providers are prompted quarterly to verify directory information through Aetna's online provider portal. Aetna conducts targeted proactive directory quality reviews and quarterly audits; outreach is made to providers without recent activity at a listed location to verify whether listings should remain. Members can report inaccurate directory listings via a link in each listing; reports are reviewed and updated by Aetna's provider data services team.
Quarterly provider prompts to verify practice/location/accepting new patients status.
Periodic directory audits and targeted outreach to verify providers without activity.
Mechanism for members to report inaccurate listings; updates handled by provider data services team.
Precertification is required for inpatient stays and certain outpatient services and supplies; in-network providers are responsible for obtaining precertification for listed services.
Consequences and appealsIf precertification is requested and denied, Aetna will explain the reasons and how to request review (appeals/complaints).
LOCUS / CALOCUS / CASII
Instrument namesLOCUS and CALOCUS/CASII are tools Aetna uses for behavioral health medical necessity reviews for commercial plan members.
PurposeThese person-centered instruments aim to match individual needs with the appropriate level of behavioral health services.
PopulationLOCUS/CALOCUS/CASII are used for child, adolescent, and adult behavioral health level-of-care determinations as applicable.
ASAM Criteria
DefinitionASAM Criteria are the American Society of Addiction Medicine's standards used to evaluate levels and types of care for substance use disorders.
Regulatory requirementUse of ASAM is required by Maryland Insurance Code Ann. § 15-802(5) for SUD clinical reviews.
Clinical roleASAM guides clinicians in evaluating medical necessity for SUD treatment placements and levels of care.
Clinical Policy Bulletins (CPBs)
DefinitionClinical Policy Bulletins (CPBs) detail services and procedures Aetna considers medically necessary, cosmetic, experimental, or unproven.
Evidence baseCPBs are based on peer-reviewed literature, evidence reviews, consensus statements, expert opinion, and guidelines from recognized organizations.
ScopeCPBs apply to both MH/SUD and medical/surgical services as part of medical necessity determinations.
Evidence-based drug uses
DefinitionEvidence-based drug uses refer to accepted safe and efficacious uses of a drug for particular illnesses or conditions, potentially including required laboratory values, population restrictions, or monitoring.
SourcesSources for evidence-based uses include FDA labeling, CMS-accepted compendia, peer-reviewed literature, clinical practice guidelines, and expert opinion.
ImplicationsEvidence-based uses may justify restrictions, monitoring, or supportive therapies as part of utilization management decisions.
Drug pipeline
DefinitionDrug pipeline refers to drugs in development (new brands, generics, biosimilars, supplemental indications) monitored to inform potential future therapy availability.
Use in policyMonitoring the drug pipeline informs formulary placement and future coverage decisions.
Relationship to formularyLate-stage developments may prompt formulary review, tier placement, or utilization management adjustments.
Cost-effectiveness / Specialty drug status / Regulatory requirements
Factors consideredCost-effectiveness, specialty drug status, and regulatory requirements inform formulary placement and controls such as tiering and prior authorization.
Cost-effectiveness roleMore cost-effective therapeutically equivalent options (generics, biosimilars, therapeutic alternatives) may be placed on lower tiers to encourage use.
Specialty drug considerationsSpecialty drugs may require close monitoring, special handling, limited distribution, or patient-specific dosing that affect coverage controls.
Negotiated charge
DefinitionNegotiated charge is the amount a network provider has agreed to accept (or that Aetna has agreed to pay), including any administrative fee; used in health coverage and surprise billing calculations.
Use in arrangementsNegotiated charge remains unchanged by value-based contracting or risk-sharing arrangements under the plan.
Surprise billing calculationSurprise bill calculations may be based on the median contracted rate among plans in the same market.
Allowable amount
DefinitionAllowable amount is the portion of an out-of-network provider's charge that is eligible for coverage; members are responsible for charges above this amount.
Geographic variationThe allowable amount depends on the geographic area where the service or supply is provided.
Member responsibilityMembers are responsible for charges above the allowable amount; plan documents explain specific calculations.
Surprise bill
DefinitionA surprise bill occurs when you unknowingly receive services from an out-of-network provider and receive a bill at the out-of-network rate you did not expect.
ProtectionsCertain out-of-network services (e.g., emergency services, non-emergency ancillary services at in-network facilities) cannot result in balance billing beyond in-network cost-sharing unless specific notice and consent were given.
ResolutionA surprise bill claim is paid based on the median contracted rate for comparable services in the same geographic region; members may request external review if needed.
Network availability / accessibility
Network availability (definition)Network availability refers to the geographic distribution and counts of appropriate practitioner types to meet member needs.
Network accessibility (definition)Network accessibility refers to members' ability to receive timely care from network providers (ability to schedule an appointment).
Parity noteAetna applies the same availability and accessibility standards to both M/S and MH/SUD services.
Network availability
Network availability specificsNetwork availability addresses the geographic distribution and number of appropriate practitioner types to meet member needs, with numeric and facility-specific standards defined in Aetna policy.
ApplicabilityMinimum availability standards apply to inpatient psychiatric facilities, residential crisis services, SUD residential treatment, acute hospitals, ICU, skilled nursing, outpatient MH clinics, outpatient SUD facilities, and other specified facility types.
Relation to filingsAetna monitors availability through Maryland Network Adequacy filings and internal analyses to ensure standards are met or exceeded.
Network accessibility
Network accessibility specificsNetwork accessibility measures members' ability to schedule timely appointments; Aetna's operational data showed median wait times below standards and MH/SUD non-urgent care available sooner than non-urgent M/S care.
Monitoring methodsAetna monitors appointment wait times and takes interventions to improve availability and accessibility, with improvements for MH/SUD from 2022 to 2023.
Directory and access featuresOnline directory filters and focus areas support member ability to locate appropriate providers, aiding accessibility.
Focus areas (MH/SUD)
MH/SUD focus areas in directoryMH/SUD provider entries include additional focus areas (e.g., diagnoses, domestic violence, grief, gender identity) to help members find appropriate providers.
PurposeFocus areas supplement licensure information because licensure alone may not indicate the concerns a provider treats.
SearchabilityThese focus-area attributes are filterable in the online directory to aid member selection.
Facility type
Facility type distinctionsFor M/S, facility types are specific (e.g., children's hospitals, MRI centers); for MH/SUD, fewer facility types exist but are supplemented with service- and level-of-care details (e.g., residential treatment for eating disorders vs substance abuse).
Member utilityService-level attributes help members distinguish facilities that treat children vs adults and different treatment levels.
Directory filteringFacility attributes are made filterable in the online directory to assist member searches equally for M/S and MH/SUD.