Aetna Better Health of Maryland requires prior authorization for select, acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services. A current list of the services that require authorization is available via the provider secure web portal. If you have questions about what is covered, consult your provider manual or call 1-866-827-2710.
Tips for requesting authorizations:
- ALWAYS verify member eligibility prior to providing services
- Complete the authorization form for all medical requests
- Attach supporting documentation when submitting
Remember, a request for prior authorization is not a guarantee of payment. Unauthorized services will not be reimbursed.
You can also fax your authorization request to 1-855-661-1967.
Utilization Management (UM) Coverage Decisions
When making coverage decisions, Aetna Better Health of Maryland follows the health care rules of the State of Maryland’s HealthChoice Program. These rules determine the type of treatments that will be covered for members. Providers can obtain the criteria to make coverage decisions by calling Provider Relations at 1-866-827-2710 and pressing *.
The HealthChoice Program’s definition of “medically necessary” means that the service or benefit is:
- Directly related to diagnostics, preventive, curative, palliative, habilitative, or ameliorative treatment of an illness, injury, disability or health condition
- Consistent with current accepted standards of good medical practice
- The most cost-effective service that can be provided without sacrificing effectiveness or access to care
- Not primarily for the convenience of the member, the member’s family or the provider
Aetna Better Health of Maryland’s staff and its providers must make health care decisions based on the appropriate care and service rules, including member eligibility. There are no rewards or financial incentives for providers or staff for the denial or reduction of any member services.
Specific criteria will be made available to you upon request.
Affirmative Statement About Incentives
Aetna Better Health of Maryland makes Utilization Management (UM) decisions based only on appropriateness of care and service and existence of coverage. We do not reward practitioners, employees, or other individuals for issuing denials of coverage. Any financial incentives Aetna Better Health of Maryland may provide to UM decision makers do not encourage them to make decisions that result in underutilization of services. We also do not use employee incentives or disincentives to encourage barriers to care and service.
If you have any questions about this statement, please call our toll-free telephone number: 1-866-827-2710, TTY 711.