Medicare Advantage prior authorization and utilization management
Describes how Aetna and Allina Health | Aetna MA plans implement Medicare-related prior authorization, utilization management, and internal coverage criteria; intended for providers and plan administrators interacting with Aetna Medicare Advantage products.
No material clinical or coverage changes in this revision.
Coverage Determination and Sources
Coverage determination sources
Covered when plan follows applicable Medicare coverage sources or internal criteria:
Internal criteria are publicly accessible and comply with CMS requirements.
Some supplemental guideline repositories referenced by this policy (for example, EviCore) contain proprietary content that Aetna cannot reproduce or distribute without permission. Access to those vendor-specific guidelines requires following the vendor’s access process (for EviCore: select Providers' Hub → Clinical Guidelines, choose a category, accept terms and conditions, and search for “Aetna”).
Prior Authorization, Documentation, and Provider Responsibilities
Prior authorization and use of internal coverage criteria
Aetna MA plans follow CMS Medicare Advantage prior authorization and coverage requirements. When Medicare statute, regulation, National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) do not fully establish coverage criteria, Aetna may use publicly accessible internal coverage criteria based on current evidence from widely used treatment guidelines or clinical literature. These internal criteria are publicly available and comply with CMS requirements.
- Aetna MA plans adhere to Medicare statutes, regulations, NCDs and LCDs when determining coverage.
- Publicly accessible internal coverage criteria are used only when CMS-covered guidance is incomplete.
- Internal criteria are based on current evidence and widely used treatment guidelines or clinical literature.
PROVIDER ACTIONS — Supplemental guideline repositories
Supplemental guideline repositories provide additional, publicly accessible clinical guidance that providers may consult when preparing authorizations and documentation for coverage determinations.
- Aetna Clinical Policy Bulletins: https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html
- Medicare Part B drugs supplemental guidelines: https://www.aetna.com/health-care-professionals/medicare/part-b-drug-um.html
- Aetna Dental Clinical Policy Bulletins: https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins.html
- American Specialty Health (ASH): https://www.ashlink.com/ASH/public/Applications/Members/ClinicalServGuide.aspx
- Evolent: https://www1.radmd.com/solutions
PROVIDER ACTIONS — Documentation and potential denial risk for insufficient records
Providers and facilities must supply detailed clinical records to support the physician's judgment for admissions. Aetna may review the entire medical record, including entries after the admission order, to determine whether inpatient admission was appropriate. If clinical records are insufficient to demonstrate medical necessity for inpatient admission, Aetna may deny payment for the admission.
- Supply complete and detailed clinical documentation that supports the physician's expectation and decision to admit.
- Aetna reviewers may consider the entire medical record and use information documented after the admission order to interpret what should have been known at the time of admission.
- Incomplete or insufficient clinical records that fail to support medical necessity for inpatient admission may result in denials.
Policy Background and Scope
When Medicare statute or regulation, National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) do not fully establish coverage criteria, Medicare Advantage plans may adopt publicly accessible internal coverage criteria based on current evidence and widely used treatment guidelines. Aetna MA plans follow CMS requirements and use these internal criteria to support medical necessity determinations where federal sources are silent or incomplete.
Key Definitions
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