Guidelines

Aetna Medicaid adopts nationally accepted evidence-based preventive health guidelines from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention. Where there is lack of sufficient evidence to recommend for or against a service by these sources, or conflicting interpretation of evidence, we may adopt recommendations from other nationally recognized sources. 

The guidelines are adopted to facilitate improved health care and appropriateness in the delivery of healthcare. They are not intended to direct coverage or benefits determinations, or treatment decisions.

Autism Update

The Department of Public Welfare has added screening for development delays and Autism Spectrum Disorders for eligible Medical Assistance (MA) recipients under 21 years of age to the MA Program Outpatient Fee Schedule effective July 1, 2009.

Aetna Medicaid adopts evidence-based clinical practice guidelines (CPGs) from nationally-recognized sources. CPGs are tools that help practitioners make decisions about appropriate health care for specific clinical circumstances. They are reviewed every two years or more frequently if national guidelines change within the two-year period.

The CPGs are provided for informational purposes only and are not intended to direct individual treatment decisions.

Our Clinical Policy Bulletins (CPBs) explain the medical and pharmacy services we may or may not cover. They are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions.

Some therapies and medications require prior authorization. A current list of the services that require authorization is available via the secure web portal or on the prior authorization requirement search tool. If you have questions about what is covered, consult your provider manual or call 1-866-638-1232.

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
  • Submit service authorizations through our secure web portal. Or, you can fax to
    1-877-363-8120.
  • Use this helpful checklist when filling out and submitting a Prior Authorization Request Form

Prior authorization notices:

Aetna Better Health of Pennsylvania and Aetna Better Health Kids does not routinely conduct post-service reviews.  Providers are expected to follow procedures for requesting prior authorizations as defined in the Provider Manual, provider’s individual contract, on the Aetna Better Health of Pennsylvania and Aetna Better Health Kids website, or as per written notice to the provider. Providers who fail to obtain the required prior authorization are instructed to submit a claim and follow the provider appeal process.