Prior authorization

There may be a time when you have a health problem that can’t be treated by your primary care physician (PCP) alone. Sometimes you may need specialty care or to see a specialist.

Prior authorization is a request to Aetna Better Health Premier Plan for you to get special services or see a specialist.  Your clinical team or PCP requests prior authorization before the service is rendered.

If the Governor of Illinois, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from Aetna Better Health Premier Plan.

During a declared disaster, if you cannot use a network provider, we will allow you to get care from out-of-network providers at no cost to you. If you cannot use a network pharmacy during a declared disaster, you will be able to fill your prescription drugs at an out-of-network pharmacy.

 

You do not need a referral or prior authorization to get emergency services.

 

How it works
Aetna Better Health Premier Plan providers follow prior authorization guidelines. If you need help understanding any of these guidelines, please call Member Services.

Aetna Better Health Premier Plan reviews urgent prior authorization requests in up to 3 business days.  It may take up to 14 days to review a routine prior authorization request.

If we need more information, we may ask for a 14-day extension. If we do not get the requested information from the requesting provider, we may deny the request. If this happens you will receive a notice of denial letter that explains your appeal rights. 

If your provider makes an urgent prior authorization request and it does not meet the urgent criteria, we will send you a letter to let you know it will be processed as a regular request. You can make a complaint, if you disagree.

If you have questions about your service authorizations, call your PCP or call Member Services.  

Important information for Aetna Better Health Premier Plan members who need specialty services

Some outpatient services and planned hospital admissions need prior authorization before the service can be covered. Please see the Evidence of Coverage - English Spanish for more information about what requires prior authorization.