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How prior authorization protects you
We take steps to help ensure your treatment is safe, effective and medically right for you. Learn how this review process works and how it helps you.
What is prior authorization?
An extra check to help ensure the right treatment
Some tests, procedures and medications need approval to be covered. Most times, this is for treatment that’s high cost or complex. Your doctor can send us a request to get that approval. This is called prior authorization. It’s also known as “preapproval” or “precertification.” The Aetna® clinical team will review your doctor’s request. They make sure the treatment is based on the best available clinical research so it’s right for you.
This extra check helps connect you to the right treatment. This can help you achieve better health sooner. That might mean a full recovery or being able to better manage a condition.
Here’s an example
You just started having lower back pain. Your doctor suggests an MRI to look into the problem. MRIs for short-term lower back pain can lead to an incorrect diagnosis. This can outweigh the benefits. So, your doctor would need to send us a prior authorization request. Our clinical team will review if the MRI is medically necessary or if other treatment options may be better.
How prior authorization works
Helping you through every step
First, your doctor gets the process started
First, your doctor gets the process started
When you visit your doctor, they help you get the prior authorization you need. We stay in touch throughout the process. And you get a timely decision.
My doctor recommended this treatment. Why does it need review?
Not everything requires this extra check. Some treatments, though, may require this review to help ensure they’re medically necessary, effective and safe. This helps you get the highest quality care.
What if I need prior authorization for a medication?
The cost of medicine is rising. So, it’s important to make sure a drug is right for you. This prior authorization is sometimes called “step therapy.”
Here’s an example. Your doctor wants to prescribe you an expensive medicine. Our clinical team may find a lower cost option to try first. The first option must meet medical guidelines.
CONDITIONS THAT OFTEN REQUIRE PRIOR AUTHORIZATION
Next, we work with your doctor on your request
Next, we work with your doctor on your request
We review each request against the highest quality clinical guidelines and scientific evidence. This includes:
- Guidelines from nationally recognized health care organizations
- Peer-reviewed, published medical journals
- Available studies on a particular topic
- Evidence-based consensus statements
- Expert opinions of health care professionals
Want to learn more? We have over 800 clinical policy bulletins that list the latest evidence-based guidelines.
How long does prior authorization take?
The review typically takes about 14 days. Then, we’ll update you and your doctor with a decision.
How do I track the status of my request?
You can log in to your member website to learn more. Log in to get updates.
Don’t have an account? Register as a new user.
Let’s go over the next steps
If your request was approved
Our clinical experts agree with your provider’s treatment advice. There’s nothing else you need to do. Have questions? Call your provider or the number on your Aetna® ID card. We’re here to help.
If your request was not approved
You’ll receive a letter from us explaining why the request wasn’t approved. In some cases, we may need more info. Other times, guidelines for medical need might not be met. If you disagree with the decision, know that you have options. You can:
- Request a peer-to-peer review. This review is a conversation between your care provider and an Aetna medical director. They can discuss the guidelines for medical need for your request. Your provider can also share more medical information.
- Request a formal appeal. Your letter from us includes steps to request a formal appeal. For more help, check out our claims appeal resources.
Prior authorization resources
For Medicare members
Here’s a guide to understand prior authorization and the steps to take.
For everyone
Learn how prior authorization can help improve member care and safety.
Legal notices
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations.