CurrentAetnaPolicy N/A

Outpatient Behavioral Health Precertification/Preauthorization Nonparticipating Provider Request form

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.

Policy Summary

PayerAetna

PolicyOutpatient Behavioral Health Precertification/Preauthorization Nonparticipating Provider Request form

Policy CodePolicy N/A

Change TypeAdministrative (form replacement)

Effective DateJan 31, 2025

Next Review Date

Key ActionSubmit the completed form with requested medical documentation via the Availity portal (preferred), confidential fax, or phone for urgent requests to initiate review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form replaces prior documents effective 2025-01-31

2fax numbers provided for submission

3submission methods listed

4form sections A–F

Criteria Used for Coverage Determination

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

Complete provider (Section A), patient (Section B), nonparticipating provider (Section C) and reason for request (Section D) fields

Provide the specific service(s) needed (e.g., consultation, diagnostic testing, specific services)

Include diagnosis code(s) related to the requested services

Include procedure/CPT code(s) and frequency for the requested services

Explain why the services can only be provided by this particular specialist/provider; attach additional clinical information as needed

Indicate whether request is for coverage of a nonparticipating provider at the in-network benefit level (Yes/No)

Indicate whether an attempt was made to find an Aetna network provider (Yes/No)

Attach supporting clinical documentation and medical records requested; failure to provide requested documentation may delay review or lead to denial

Submission methods: Availity portal (preferred), confidential fax (commercial or Medicare fax numbers), or phone for urgent requests

Provider must attest that information is truthful; fraudulent submissions are subject to criminal and civil penalties

Completion and submission of the form does not constitute approval; Aetna will perform a clinical review and make a coverage determination after receipt of requested documentation

Aetna will contact the office/facility once a coverage determination is made

Required Codes and Fields

Requested service codesmixed

Diagnosis codes	Field requests diagnosis code(s) related to requested services
Procedure/CPT codes	Field requests CPT/procedure codes and frequency for services

Required coding fields — diagnosis and procedure/CPT code fields required on form

Diagnosis codesForm requires entry of diagnosis code(s) related to the requested service (Section D, item 2)

Procedure/CPT codesForm requires procedure/CPT code(s) and frequency for the requested service (Section D, item 3)

Service descriptionForm requests the specific service(s) needed (e.g., consultation, diagnostic testing) to be listed alongside codes (Section D, item 1)

Submission, Use Limits, and Post-Submission Review

Prior Authorization

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.

Note

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.

Documentation Required

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

Precertification definition — utilization review process

DefinitionPrecertification is the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage prior to the start of services.

Scope noteThis definition clarifies it is not the Texas statutory definition of precertification and is not a representation of payment for fully insured HMO and PPO members.

ApplicationUsed to evaluate coverage requests before services begin; completion of the form and submission of documentation initiates review but does not itself guarantee approval.