Insurance regulations by state

Health care provider timely payment and grievance law regulatory bulletin 2006-021 (PDF)

California assembly bill 2193 requires maternal mental health screening (PDF)

HMO dispute resolution policy (PDF)

Non-discrimination notice (PDF)

Provider disclosure form (PDF) 

Colorado Regulation 425 Credentialing of Physician By Carriers (PDF)

Colorado medical/behavioral health prior authorization report - 2023 (PDF)

Language services

Aetna provides free aids and services to people with disabilities and free language services to people whose primary language is not English. This includes language interpreters and plan details written in other languages. If a patient needs these services, contact the number on the patient’s ID card.

Pharmacy prior authorization statistics for commercial insured business

Colorado pharmacy prior authorization statistics – 2023 (XLSX)

Connecticut regulatory amendment to Aetna (PDF)

Aetna is required to comply with various federal and state behavioral health coverage requirements including but not limited to Affordable Care Act’s Essential Health Benefits requirements, the Mental Health Addition Equity Act, and Florida Statutes § 627.668 ST § 627.669. If you have any questions about your behavioral health coverage provided under these laws please contact us at 1-800-424-4047 (TTY: 711).

Additionally, you can reach out to the Florida Division of Consumer Services with questions at 1-877-MY-FL-CFO (1-877-693-5236). You can also visit their website to learn how to contact consumer services.

You can also get help to file consumer complaints with the Florida Division of Consumer Services on their website.

Provider training – Dual-eligible special needs plans model of care (D-SNP MOC) (PDF)

Pharmacy prior authorization statistics for commercial insured business

Georgia pharmacy prior authorization report - 2021 (PDF)

Georgia pharmacy prior authorization statistics – 2022 (XLSX)

Georgia pharmacy prior authorization statistics – 2023 (XLSX)

Aetna® is required to comply with Illinois state law, which allows external stakeholders to request training on behavioral health medical necessity criteria. If you’d like to request this training, send an email to our team.

Prior authorization statistics for commercial insured business

Illinois pharmacy prior authorization statistics – 2023 (XLSX)

Illinois Aetna prior authorization statistics – 2022 (PDF)

Illinois specialty pharmacy prior authorization statistics – 2022 (PDF)

Illinois eviCore prior authorization statistics – 2022 (PDF)

Illinois Optum prior authorization statistics – 2022 (PDF)

Prior authorization statistics for commercial fully insured business

Indiana Aetna prior authorization statistics – 2023 (PDF)

HMO-based plans (PDF)

Prior authorization bulletin (PDF)

Aetna MA BHCA provider training (PDF)

Aetna MA BHCA provider training questions and answers (PDF)

To download the MDHHS-573 Nonopioid Directive form, visit the Michigan opioid resources page and look under “Additional Resources.”

Prior authorization statistics for commercial insured business

Minnesota prior authorization statistics – 2023 (PDF)

Minnesota specialty pharmacy medical prior authorization statistics – 2022 (PDF)

Minnesota pharmacy prior authorization statistics (ALIC) – 2023 (XLSX)

Minnesota pharmacy prior authorization statistics (ALIC) – 2022 (XLSX)

Precertification

Sometimes we will pay for care only if we have given an approval before a member receives care. The Aetna^® PCP or network provider is responsible for obtaining this approval for covered in-network services.

You can find Aetna’s precertification list on our provider website. Alternatively, you can call Member Services to find the services requiring prior authorizations. We cover medically necessary treatment, procedures, therapies and diagnostic ambulatory and inpatient services. We may require submission of clinical information to confirm medical necessity of the requested service, treatment, procedure, diagnostic service, therapy, ambulatory or inpatient service. If the requested information is not received, an administrative denial for lack of clinical information will be made. This will apply in cases where no information is received or if some clinical information is submitted but is inadequate to approve a request for authorization. 

Check our precertification lists

Administrative denials for lack of clinical information

If a request for authorization is not certified due to lack of clinical information required to make a medical necessity determination and no appeal has been submitted, we will review the request with additional information as follows:

Precertification requests

• When received within fourteen (14) calendar days of the letter of noncertification; and peer to peer review has not been completed for services that have not yet begun. Aetna will review the additional information with the original request and make a determination based on all information received at that time.
• When received within fourteen (14) calendar days of the letter of noncertification and peer to peer review has been completed. Aetna will review the additional information along with the original submission as a new precertification request.
• When received more than 14 days from the date of the denial letter for services that have not yet started and the missing information is received within six (6) months of the date of the denial letter. Aetna will review the additional information along with the original submission as a new precertification request.

Concurrent review requests

While the member is receiving ongoing concurrent inpatient or ambulatory services, or within five (5) days of termination of these services. Aetna will review the additional information along with the original submission and render a determination.

After the member has been discharged from an acute inpatient event and an adverse determination was issued due to lack of clinical information to support medical necessity, and clinical information is received within five (5) business days of hospital discharge but prior to peer-to-peer review or appeal request. Aetna will review the additional information along with the original submission and render a determination.

Learn more about Concurrent review 

Aetna will review the request and render a determination within Missouri statutory time frames.

Montana non-contracted provider lien (PDF)

Present on admission indicator code (PDF)

Continuation of benefits due to total disability form (PDF) 

Handicapped child attending physician statement – for behavioral health conditions of all ages and medical conditions for dependents age 18 and younger (PDF)

Adult medical attending physician statement – for medical conditions for subscriber and dependent s over the age of 18 (PDF)

Nonparticipating facility itemized bill review (PDF)

Provider appeal procedure (PDF)

New claims review process for observation room charges (PDF)

New York evaluation and management program claim and code review (PDF)

Company affiliates list (PDF)

New York regulatory amendment to Aetna (PDF)

New York surprise/emergency balance bills and independent dispute resolution process (PDF)

New York third party claim and coding edits (PDF)

Refusal to enroll in electronic funds transfer (EFT) form (PDF)

Confidential communication requests for enrollees (PDF)

Pennsylvania Act 106 (PDF)

Rhode Island web notice of complaint appeal and grievance process (PDF)

Texas telemedicine and telehealth services

Texas preauthorization

Pharmacy prior authorization statistics for commercial insured business

Texas pharmacy prior authorization statistics – 2022 (XLSX)

Texas pharmacy prior authorization statistics – 2023 (XLSX)

Washington extenuating circumstances policy (PDF)

Washington Utilization Management and Exception Process (PDF)