The purpose of the utilization management program is to manage the use of health-care resources so members receive the most medically appropriate and cost-effective health care that will improve their medical and behavioral health outcomes. The utilization management department consists of clinical and non-clinical staff members.
Utilization Management Department is responsible to monitor the use of designated services before the services are delivered in order to confirm that they are:
- Provided at an appropriate level of care and place of service
- Included in the defined benefits, and are appropriate, timely and cost-effective
- Accurately documented in order to facilitate accurate and timely reimbursement
Aetna Better Health of Texas Utilization Management staff has expertise in physical, behavioral health care services. Staff receives training to combine clinical skills with service techniques to support the Aetna Better Health of Texas utilization management processes. Our staff receives initial and ongoing training on a regular basis, but no less than annually.
Aetna Better Health’s utilization management function identifies both over- and under-utilization patterns for inpatient and outpatient services. This review must consider the expected utilization of services regarding the characteristics and health care needs of the member population. Compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member.
The Utilization Management department has a toll‑free voicemail phone line available 24 hours a day, 7 days a week. The Utilization Management department conducts outgoing communications with practitioners and providers regarding authorizations during the hours of 8 a.m. and 5 p.m. CST. This telephone help line will have staff to respond to practitioner and provider questions about authorization. This voice mail can be access by calling Member Services at:
Medicaid STAR 1-800-248-7767 (Bexar), 1-800-306-8612 (Tarrant)
Medicaid STAR Kids 1-844-STRKIDS (1-844-787-5437)
CHIP or CHIP Perinate 1-866-818-0959 (Bexar), 1-800-245-5380 (Tarrant)
Member Services can also provide callers with TDD/TTY and language assistance services for providers and members who need them. Aetna Better Health of Texas requires Utilization Management staff to identify themselves by name, title, and organization name when initiating or returning calls regarding UM inquiries. And upon request, verbally facility personnel; the attending physician and other ordering practitioners/providers of specific utilization management requirements and procedures.
Important fax numbers for you to know
Prior authorizations: fax requests to 1‑866‑835‑9589
Concurrent review: fax requests to 1‑866‑706‑0529
Prior Authorization is the prospective review of the medical necessity and appropriateness of the selected health services. The prior authorization list is reviewed and revised periodically to ensure only those services that are medical management issues are subject to review by the health plan and approved before the services are eligible for reimbursement.
The process for requesting services on the prior authorization list:
- Complete the Texas Standard Prior Authorization Request Form.
- Fax to Aetna Better Health Prior Authorization Unit at 1-866-835-9589.
- Include any pertinent clinical information that supports the medical necessity of the request, such as a Title XIX form, test results, information about failed conservative treatment.
- Allow at least 3 business days for a response if medically appropriate. Urgent requests for medically non- urgent services will be handled within the timeframes for a routine request.
- Respond to requests for additional information timely. The turnaround time begins when all information necessary to make determination is received.
Medical Management staff will review the information submitted for medical necessity, verify eligibility and benefits for the member and issue a determination. Approvals will be communicated to the requesting provider. Adverse determinations will be communicated to the requesting provider immediately followed by a written notice of the determination and appeal rights. View the most up to date Prior Authorization list.
The concurrent review (inpatient) function provides a way to evaluate, during a member’s stay in an acute care or non-acute facility, the medical necessity of the admission and the appropriateness of the services provided. Admissions are reviewed for medical necessity and continuing services are reviewed for the appropriate use of inpatient medical resources.
Availability of Utilization Management Criteria
Aetna Better Health of Texas employees make clinical decisions regarding members’ health based on the most appropriate care and service available. We make medical necessity determinations based on established criteria. The criteria used to make the determination are available to practitioners at any time by contacting the utilization management department to obtain a copy.