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The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT ®), copyright 2022 by the American Medical Association (AMA).Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search." Visit the secure website, available through for more information.
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Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment.
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Applies to: Aetna Choice ® POS, Aetna Choice POS II, Aetna Medicare ℠ Plan (PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund ® products, Aetna Health Network Only ℠, Aetna Health Network Option ℠, Aetna Open Access ® Elect Choice ®, Aetna Open Access HMO, Aetna Open Access Managed Choice ®, Open Access Aetna Select ℠, Elect Choice, HMO, Managed Choice POS, Open Choice ®, Quality Point-of-Service ® (QPOS ®), and Aetna Select ℠ benefits plans and all products that may include the Aexcel ®, Choose and Save ℠, Aetna Performance Network or Savings Plus networks.It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage.Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
The member's benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. TriNet provides its customers with a tool to assist them in conducting individualized risk assessments prior to making final FLSA status determinations for their employees.By clicking on “I Accept”, I acknowledge and accept that:
Different exemptions and criteria may apply at the industry, local, or state levels. There may be other requirements that must be met for nonexempt employees depending on the work location and industry, such as providing compliant meal and rest breaks.įact Sheet 17A: Exemption for Executive, Administrative, Professional, Computer & Outside Sales Employees Under the Fair Labor Standards Act (FLSA) outlines the federal criteria for each of the white-collar exemptions under which an employee may be designated under the FLSA. Certain employees may be designated as exempt from minimum wage and overtime pay under administrative, professional, executive, computer or outside sales exemptions, among other potential exemptions, if they satisfy both a job duties test and a salary basis test. The Fair Labor Standards Act (FLSA) and various industry, local and state laws and regulations establish criteria for minimum wage and overtime pay. The main difference is that nonexempt employees are subject to minimum wage and overtime pay, among other requirements, while exempt employees are not.
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