Some health care services need to be approved

Aetna Better Health of Maryland must pre-approve some services before you can get them. We call this prior authorization. This means that your providers must get permission from us to provide certain services. They know how to do this. We’ll work together to make sure the service is what you need.

Except for family planning and emergency care, all out-of-network services require pre-approval. You may have to pay for your services if you don’t get pre-approval for services that:

  • Are given by an out-of-network provider
  • Require pre-approval
  • Are not covered by Aetna Better Health of Maryland

The following are the steps for pre-approval:

  • Your provider gives us information about the services they think you need.
  • We review the information.
  • A Medical Director will review the information for any unapproved requests.
  • You and your provider will get a letter when a service is denied.
  • Your letter will explain why your request is denied.

If a service is denied, you or your provider can file an appeal.

Aetna Better Health of Maryland makes Utilization Management (UM) reviews to decide the care you receive. What we decide is based only on your medical need for care and service. We check to make sure you are a covered member. We do not reward doctors or anyone else for service that is denied. Our UM staff members do not decide based on members getting less care or service. We do not reward or punish our staff for blocking you from care and service. Any rewards we give to those who provide care are based on other reasons.

If you have any questions about this statement, please call our toll-free phone number: 1-866-827-2710, TTY 711.