Quality Management

Availability of Criteria

Providers and members have the right to request a copy of a guideline that Aetna Better Health has used to make a treatment authorization decision. Specific criteria or guidelines are available upon request with the following disclosure:

“The material provided to you are guidelines used by this plan to authorize, modify, or deny care for the person with similar illnesses or conditions. Care and treatment may vary depending on individual need and the benefits covered under your contract.” If you would like to obtain a copy of the criteria, call Member Services at 1-855-232-3596.

Affirmative Statements about Incentives

We based our utilization management (UM) decisions on appropriateness of care and service, subject to covered benefits.  If we contract with practitioners and providers to make UM decisions, we require that they make decisions based only on appropriateness of care and service. We do not provide incentives or make financial arrangements that encourage staff or contracted providers making UM decisions to issue denials, limitations or discontinuation of medically necessary care or to make decisions that lead to under-utilization.  This includes our policies and practices in:

  • Hiring
  • Compensation
  • Termination
  • Promotion
  • Any similar matters

We do not take any action to penalize or discourage members or providers with regard to appeals, disputes or other disagreements about utilization management of covered care.  Providers and practitioners are free to advocate on behalf of members within the utilization management process.

Participating providers are encouraged to give us input and feedback. For information about how to join an Aetna Better Health of New Jersey committee or for a written copy of the quality program description, please call our Quality Management Department at 609-282-8160.