CurrentAetnaPolicy N/A

Waiver/Elimination of Prior Authorization for Extenuating Circumstances

Governs procedures for participating providers/facilities in Washington State to request waiver or elimination of prior authorization requirements due to extenuating circumstances; does not apply to self-funded, federal, Medicare, or prescription drug prior authorization programs.

Policy Summary

PayerAetna

PolicyWaiver/Elimination of Prior Authorization for Extenuating Circumstances

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvider must notify Aetna (call 888-632-3862 before filing a claim or send written notice after denial) and request waiver with a detailed explanation of the extenuating circumstance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180Timeliness limit (days)

888-632-3862Precert phone

Provider Resolution Team, PO Box 14020Mailing address

WAC 284-43-2060Governing reg

Extenuating Circumstance Waiver Criteria

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Extenuating circumstance waiver criteria and process

Criteria and required provider actions to request waiver/elimination of prior authorization:

Aetna will waive penalties for failing to pre-certify health care services identified on the Precertification List when an extenuating circumstance prevented obtaining the required prior authorization.

An extenuating circumstance is an unforeseen event or set of circumstances which adversely affects the ability of a participating provider or facility to request prior authorization prior to service delivery.

Provider notification options

Before claim submission: Provider or facility must call Aetna's precertification department at 888-632-3862 prior to filing a claim, specifically request that Aetna waive/eliminate the precertification requirement, and provide a detailed explanation of the extenuating circumstance and how it resulted in not obtaining prior authorization.
After claim denial (before appeal initiation): Provider or facility must send written notice to Aetna's Provider Resolution Team identifying the denied claim, requesting waiver/elimination of the prior authorization requirement, and describing in sufficient detail the nature and type of the extenuating circumstance. Mail to: Provider Resolution Team, PO Box 14020 Lexington KY 40512.
Once an appeal has been initiated: Provider or facility must provide written notice to Aetna's grievance and appeal department at any time prior to receiving Aetna's written appeal determination; notice must identify the denied claim, request waiver/elimination, and describe the extenuating circumstance. If an adverse determination has already been issued, include a copy of that notice. Send to: Provider Resolution Team, PO Box 14020 Lexington KY 40512.

Timeliness limit: If Aetna receives notice of an extenuating circumstance more than 180 calendar days after the date of claim denial, Aetna will not eliminate the administrative requirement to prior authorize the services or the penalty for failing to obtain authorization.

Scope exclusions: This procedure applies to participating providers and facilities in accordance with Washington regulation and does not apply to self-funded plans, federal employee health benefits, other federally regulated programs, Medicare products, or prescription drug prior authorization requirements.

Coding and Timeliness

Not applicablemixed

No codes listed

Timeliness threshold for consideration

Timeliness threshold for considerationNotice must be received within 180 calendar days of the date of claim denial; notices received after 180 calendar days will not be accepted.

Required identification in noticeNotice must identify the claim that was denied for failing to obtain prior authorization.

Required contents of noticeRequest that the administrative prior authorization requirement be waived or eliminated and describe in sufficient detail the nature and type of extenuating circumstance.

Notification and Waiver Request Process

Prior Authorization

Notification process for requesting waiver/elimination of prior authorization

A participating provider or facility must notify Aetna if an extenuating circumstance prevented timely prior authorization. The administrative requirement is not automatically eliminated — the provider must request that Aetna waive or eliminate the precertification requirement and explain the circumstances.

Contact Aetna's precertification department at 888-632-3862 before filing a claim to request the waiver and provide a detailed explanation of the extenuating circumstance and how it prevented obtaining prior authorization.

Note

Aetna's stance on waiving penalties

Aetna will waive penalties for failing to pre-certify services on the Precertification List when an extenuating circumstance prevented obtaining prior authorization. An extenuating circumstance is an unforeseen event or set of circumstances that adversely affects the provider's ability to request prior authorization prior to service delivery.

If a claim has already been denied: for Washington State, notify Aetna's complaint, grievance and appeal department in writing following receipt of the claim denial. Send notice to: Provider Resolution Team, PO Box 14020 Lexington KY 40512. Include identification of the denied claim, a request to waive/eliminate the prior authorization requirement, and a detailed description of the extenuating circumstance.
If an appeal has been initiated: you may notify the complaint, grievance and appeal department in writing at any time prior to receiving Aetna's written appeal determination. If an adverse determination has already been issued, include a copy of that notice. If notice is received more than 180 calendar days after the date of claim denial, Aetna will not eliminate the administrative requirement or the penalty.

Key Definitions

Extenuating circumstance

DefinitionAn extenuating circumstance is an unforeseen event or set of circumstances which adversely affects the ability of a participating provider or facility to request prior authorization prior to service delivery.

Policy effectAetna will waive penalties for failing to precertify services on the Precertification List when an extenuating circumstance prevented obtaining required prior authorization.

Scope limitationApplies to participating providers/facilities seeking waiver of prior authorization penalties under this procedure (see exclusions in full policy).

Examples of extenuating circumstances

Unable to identify correct carrier/repProvider or facility cannot identify from which carrier or its designated/contracted representative to request prior authorization.

Unable to anticipate need for prior authorizationProvider or facility is unable to anticipate the need for prior authorization before or while performing a service.

Insufficient time after dischargeAn enrollee is discharged from a facility and insufficient time exists to obtain approval for institutional or home health services prior to delivery.