![]() ![]() The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage.Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The independent reviewer will contact you and Aetna Better Health to obtain all the necessary documents.By clicking on “I Accept”, I acknowledge and accept that: Reminder: Don’t send medical records to the Louisiana Department of Health. ![]() Send the completed request form with all required documents listed on the form via certified mail to the Louisiana Department of Health: Your favor: We’ll pay the disputed claims, along with 12% interest, within 20 calendar days of the final decision.Ĭomplete the Louisiana Department of Health independent review request form.Our favor: You’ll need to reimburse us for this fee within 10 days of the final decision.If the independent reviewer renders their decision in: The fee for conducting an independent review is $750. Don’t respond to the independent reconsideration review request within the 45 calendar days allowed.You may then submit the independent review to the Louisiana Department of Health if we: ![]() We'll acknowledge receipt of the independent reconsideration review in writing within 5 calendar days and make a decision within 45 days of receipt.Ĭomplete the independent reconsideration review form (PDF), with all documentation, and send via email (preferred) or mail to:
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