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. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.By clicking on “I Accept”, I acknowledge and accept that: OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. If during your Level 1 appeal ("reconsideration") your Medicare Advantage plan does not decide in your favor, it is required to forward your appeal to an independent outside entity for a Level 2 review. If your Medicare Advantage plan fails to meet the established deadlines, it is required to forward your appeal to an independent outside entity for a Level 2 review.
Your plan does not meet the response deadline. Your Level 1 appeal ("reconsideration") will automatically be forwarded to Level 2 of the appeals process in the following instances:
If you are receiving services in an inpatient hospital, skilled nursing facility, home health agency or comprehensive rehabilitation facility, you may request an immediate review by a Quality Improvement Organization, if you disagree with your Medicare Advantage plan's decision to discharge you or discontinue services. You or your physician may request an expedited reconsideration by your Medicare Advantage plan in situations where the standard reconsideration time frame might jeopardize your health, life, or ability to regain maximum function. Special Circumstances for Expedited Review 60 days if the decision involves a request for payment.30 days if the decision involves a request for a service.In most cases, your plan will notify you of its reconsideration decision within: When You Will Get a Response (i.e., "reconsideration decision")
AETNA MEDICARE TIMELY FILING HOW TO
If you are in a Medicare Advantage plan, you can appeal the plan's decision to not pay for, not allow, or stop a service that you think should be covered or provided.
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