Outpatient Behavioral Health Precertification/Preauthorization Nonparticipating Provider Request form
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Governs use and submission of the Aetna Outpatient Behavioral Health nonparticipating provider request form for precertification/preauthorization of services; affects nonparticipating providers and requesting providers submitting on behalf of Aetna members (including Medicare and commercial plans) in applicable markets.
No material clinical or coverage changes in this revision.
Criteria Used for Coverage Determination
Coverage determination inputs
Form captures information necessary for Aetna to perform clinical review and determine coverage for nonparticipating provider services; completion and submission of requested medical records is required for review.
Submission methods: Availity portal (preferred), confidential fax (commercial or Medicare fax numbers), or phone for urgent requests
Aetna will contact the office/facility once a coverage determination is made
Required Codes and Fields
| Diagnosis codes | Field requests diagnosis code(s) related to requested services |
| Procedure/CPT codes | Field requests CPT/procedure codes and frequency for services |
Submission, Use Limits, and Post-Submission Review
Submission and initiation instructions
How to submit and initiate a precertification request. You cannot use this form to initiate a precertification/preauthorization request. To initiate a request, submit electronically via our secure provider portal or by calling the Precertification Department. Completing and sending this form alone does not start the precertification process.
- Preferred submission: Upload at Availity.com (secure provider portal).
- Commercial plans fax (confidential): 1-888-463-1309.
- Medicare plans fax (confidential): 959-282-8799.
- For urgent requests call: HMO and QPOS: 1-800-624-0756 (TTY: 711); All other plans: 1-888-632-3862 (TTY: 711).
- This form does not initiate a request — use the portal or call the Precertification Department to start precertification.
Post-submission review
Post-submission clinical review. Once Aetna receives the completed form and all requested medical documentation, we will perform a clinical review. Completing or faxing this form is not an approval; coverage determination is made after clinical review and you will be notified of the decision.
- A clinical review will be completed after receipt of all requested documentation.
- Submission of this form and documentation is NOT a determination of coverage; a decision will be issued after review.
- Aetna will contact the submitting office/facility with the coverage determination.
State use limitation
State use limitation. Do not use this form for commercial plans in Maryland or Massachusetts. This form may be used for Medicare Advantage plans in those states.
- Not for use with commercial plans in Maryland or Massachusetts.
- May be used for Medicare Advantage plans in Maryland and Massachusetts.
Terminology
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.