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Submitted URL: https://click.e.myplanportal.com/u/?qs=f15853cf5223ffdd176dc15f15ab7e5de8853ac6f4257e5b2edb3c0a7e5e545fbe94d29bf286e73e812b027928...
Effective URL: https://www.aetna.com/individuals-families.html?cid=eml-m-1067369&sub=301865429
Submission: On October 07 via api from US — Scanned from DE
Effective URL: https://www.aetna.com/individuals-families.html?cid=eml-m-1067369&sub=301865429
Submission: On October 07 via api from US — Scanned from DE
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APPLIED BEHAVIOR ANALYSIS MEDICAL NECESSITY GUIDE
By clicking on “I Accept”, I acknowledge and accept that:
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 ABA Medical
Necessity Guide does not constitute medical advice. Treating providers are
solely responsible for medical advice and treatment of members. Members should
discuss any matters related to their coverage or condition with their treating
provider.
Each benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. 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.
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. The member's
benefit plan determines coverage. Some plans exclude coverage for services or
supplies that Aetna considers medically necessary.
Please note also that the ABA Medical Necessity Guide may be updated and are,
therefore, subject to change.
Medical necessity determinations in connection with coverage decisions are made
on a case-by-case basis. 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.
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ASAM TERMS AND CONDITIONS
By clicking on “I accept”, I acknowledge and accept that:
Licensee's use and interpretation of the American Society of Addiction
Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring
Conditions does not imply that the American Society of Addiction Medicine has
either participated in or concurs with the disposition of a claim for benefits.
This excerpt is provided for use in connection with the review of a claim for
benefits and may not be reproduced or used for any other purpose.
Copyright 2015 by the American Society of Addiction Medicine. Reprinted with
permission. No third party may copy this document in whole or in part in any
format or medium without the prior written consent of ASAM.
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PRECERTIFICATION LISTS
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Should the following terms and conditions be acceptable to you, please indicate
your agreement and acceptance by selecting the button below labeled "I Accept".
* 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. It does
not mean precertification as defined by Texas law, as a reliable
representation of payment of care or services to fully insured HMO and PPO
members.
* Applies to: Aetna Choice® POS, Aetna Choice POS II, Aetna Medicare℠ Plan
(PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund® products, Aetna
Health Network Only℠, Aetna Health Network Option℠, Aetna Open Access® Elect
Choice®, Aetna Open Access HMO, Aetna Open Access Managed Choice®, Open
Access Aetna Select℠, Elect Choice, HMO, Managed Choice POS, Open Choice®,
Quality Point-of-Service® (QPOS®), and Aetna Select℠ benefits plans and all
products that may include the Aexcel®, Choose and Save℠, Aetna Performance
Network or Savings Plus networks. Not all plans are offered in all service
areas.
* All services deemed "never effective" are excluded from coverage. Aetna
defines a service as "never effective" when it is not recognized according to
professional standards of safety and effectiveness in the United States for
diagnosis, care or treatment. Visit the secure website, available through
www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding
Tool," "Clinical Policy Code Search."
* The five character codes included in the Aetna Precertification Code Search
Tool are obtained from Current Procedural Terminology (CPT®), copyright 2020
by the American Medical Association (AMA). CPT is developed by the AMA as a
listing of descriptive terms and five character identifying codes and
modifiers for reporting medical services and procedures performed by
physicians.
* The responsibility for the content of Aetna Precertification Code Search Tool
is with Aetna and no endorsement by the AMA is intended or should be implied.
The AMA disclaims responsibility for any consequences or liability
attributable or related to any use, nonuse or interpretation of information
contained in Aetna Precertification Code Search Tool. No fee schedules, basic
unit values, relative value guides, conversion factors or scales are included
in any part of CPT. Any use of CPT outside of Aetna Precertification Code
Search Tool should refer to the most Current Procedural Terminology which
contains the complete and most current listing of CPT codes and descriptive
terms. Applicable FARS/DFARS apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")
* CPT only Copyright 2020 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association. You, your
employees and agents are authorized to use CPT only as contained in Aetna
Precertification Code Search Tool solely for your own personal use in
directly participating in health care programs administered by Aetna, Inc.
You acknowledge that AMA holds all copyright, trademark and other rights in
CPT. Any use not authorized herein is prohibited, including by way of
illustration and not by way of limitation, making copies of CPT for resale
and/or license, transferring copies of CPT to any party not bound by this
agreement, creating any modified or derivative work of CPT, or making any
commercial use of CPT. License to sue CPT for any use not authorized herein
must be obtained through the American Medical Association, CPT Intellectual
Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications
are available at the American Medical Association Web site,
www.ama-assn.org/go/cpt.
U.S. Government Rights
* This product includes CPT which is commercial technical data and/or computer
data bases and/or commercial computer software and/or commercial computer
software documentation, as applicable which were developed exclusively at
private expense by the American Medical Association, 515 North State Street,
Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer
data bases and/or computer software and/or computer software documentation
are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)
(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June
1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department
of Defense procurements and the limited rights restrictions of FAR 52.227-14
(June 1987) and/or subject to the restricted rights provisions of FAR
52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any
applicable agency FAR Supplements, for non-Department of Defense Federal
procurements.
Disclaimer of Warranties and Liabilities.
* CPT is provided "as is" without warranty of any kind, either expressed or
implied, including but not limited to the implied warranties of
merchantability and fitness for a particular purpose. No fee schedules, basic
unit, relative values or related listings are included in CPT. The American
Medical Association (AMA) does not directly or indirectly practice medicine
or dispense medical services. The responsibility for the content of this
product is with Aetna, Inc. and no endorsement by the AMA is intended or
implied. The AMA disclaims responsibility for any consequences or liability
attributable to or related to any use, non-use, or interpretation of
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Accept".
* The information contained on this website and the products outlined here may
not reflect product design or product availability in Arizona. Therefore,
Arizona residents, members, employers and brokers must contact Aetna directly
or their employers for information regarding Aetna products and services.
* This information is neither an offer of coverage nor medical advice. It is
only a partial, general description of plan or program benefits and does not
constitute a contract. In case of a conflict between your plan documents and
this information, the plan documents will govern.
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DENTAL CLINICAL POLICY BULLETINS
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* Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
administering plan benefits and do not constitute dental advice. Treating
providers are solely responsible for dental advice and treatment of members.
Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to
their coverage or condition with their treating provider.
* While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
administering plan benefits, they do not constitute a description of plan
benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's
current determinations of whether certain services or supplies are medically
necessary, based upon a review of available clinical information. Each
benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. 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.
Aetna's 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). Your benefits plan determines
coverage. Some plans exclude coverage for services or supplies that Aetna
considers medically necessary. If there is a discrepancy between this policy
and a member's plan of benefits, the benefits plan will govern. In addition,
coverage may be mandated by applicable legal requirements of a State or the
Federal government.
* Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly
updated and are therefore subject to change.
* Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and
are designed to be used by our professional staff in making clinical
determinations in connection with coverage decisions, members should review
these Bulletins with their providers so they may fully understand our
policies.
* Under certain plans, if more than one service can be used to treat a covered
person's dental condition, Aetna may decide to authorize coverage only for a
less costly covered service provided that certain terms are met.
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MEDICAL CLINICAL POLICY BULLETINS
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Should the following terms and conditions be acceptable to you, please indicate
your agreement and acceptance by selecting the button below labeled "I Accept".
* Aetna Clinical Policy Bulletins (CPBs) are developed to assist in
administering plan benefits and do not constitute medical advice. Treating
providers are solely responsible for medical advice and treatment of members.
Members should discuss any Clinical Policy Bulletin (CPB) related to their
coverage or condition with their treating provider.
* While the Clinical Policy Bulletins (CPBs) are developed to assist in
administering plan benefits, they do not constitute a description of plan
benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination
of whether certain services or supplies are medically necessary, experimental
and investigational, or cosmetic. Aetna has reached these conclusions based
upon a review of currently available clinical information (including clinical
outcome studies in the peer-reviewed published medical literature, regulatory
status of the technology, evidence-based guidelines of public health and
health research agencies, evidence-based guidelines and positions of leading
national health professional organizations, views of physicians practicing in
relevant clinical areas, and other relevant factors).
* Aetna makes no representations and accepts no liability with respect to the
content of any external information cited or relied upon in the Clinical
Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions
reflected in the Clinical Policy Bulletins (CPBs), including any reference to
a specific provider, product, process or service by name, trademark,
manufacturer, constitute Aetna's opinion and are made without any intent to
defame. Aetna expressly reserves the right to revise these conclusions as
clinical information changes, and welcomes further relevant information
including correction of any factual error.
* CPBs include references to standard HIPAA compliant code sets to assist with
search functions and to facilitate billing and payment for covered services.
New and revised codes are added to the CPBs as they are updated. When
billing, you must use the most appropriate code as of the effective date of
the submission. Unlisted, unspecified and nonspecific codes should be
avoided.
* Each benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. 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.
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. The
member's benefit plan determines coverage. Some plans exclude coverage for
services or supplies that Aetna considers medically necessary. If there is a
discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of
benefits, the benefits plan will govern.
* In addition, coverage may be mandated by applicable legal requirements of a
State, the Federal government or CMS for Medicare and Medicaid members.
See CMS's Medicare Coverage Center
* Please note also that Clinical Policy Bulletins (CPBs) are regularly updated
and are therefore subject to change.
* Since Clinical Policy Bulletins (CPBs) can be highly technical and are
designed to be used by our professional staff in making clinical
determinations in connection with coverage decisions, members should review
these Bulletins with their providers so they may fully understand our
policies.
* While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy,
medical necessity determinations in connection with coverage decisions are
made on a case by case basis. In the event that a member disagrees with a
coverage determination, Aetna provides its members with the right to appeal
the decision. In addition, a member may have an opportunity for an
independent external review of coverage denials based on medical necessity or
regarding the experimental and investigational status when the service or
supply in question for which the member is financially responsible is $500 or
greater. However, applicable state mandates will take precedence with respect
to fully insured plans and self-funded non-ERISA (e.g., government, school
boards, church) plans.
See Aetna's External Review Program
* The five character codes included in the Aetna Clinical Policy Bulletins
(CPBs) are obtained from Current Procedural Terminology (CPT®), copyright
2015 by the American Medical Association (AMA). CPT is developed by the AMA
as a listing of descriptive terms and five character identifying codes and
modifiers for reporting medical services and procedures performed by
physicians.
* The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs)
is with Aetna and no endorsement by the AMA is intended or should be implied.
The AMA disclaims responsibility for any consequences or liability
attributable or related to any use, nonuse or interpretation of information
contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic
unit values, relative value guides, conversion factors or scales are included
in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins
(CPBs) should refer to the most current Current Procedural Terminology which
contains the complete and most current listing of CPT codes and descriptive
terms. Applicable FARS/DFARS apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")
CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT
is a registered trademark of the American Medical Association.
You, your employees and agents are authorized to use CPT only as contained in
Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in
directly participating in healthcare programs administered by Aetna, Inc. You
acknowledge that AMA holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration
and not by way of limitation, making copies of CPT for resale and/or license,
transferring copies of CPT to any party not bound by this agreement, creating
any modified or derivative work of CPT, or making any commercial use of CPT.
License to use CPT for any use not authorized herein must be obtained through
the American Medical Association, CPT Intellectual Property Services, 515 N.
State Street, Chicago, Illinois 60610. Applications are available at the
American Medical Association Web site, www.ama-assn.org/go/cpt.
Go to the American Medical Association Web site
U.S. Government Rights
This product includes CPT which is commercial technical data and/or computer
data bases and/or commercial computer software and/or commercial computer
software documentation, as applicable which were developed exclusively at
private expense by the American Medical Association, 515 North State Street,
Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer data
bases and/or computer software and/or computer software documentation are
subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June
1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and
DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense
procurements and the limited rights restrictions of FAR 52.227-14 (June 1987)
and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987)
and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR
Supplements, for non-Department of Defense Federal procurements.
Disclaimer of Warranties and Liabilities.
CPT is provided "as is" without warranty of any kind, either expressed or
implied, including but not limited to the implied warranties of merchantability
and fitness for a particular purpose. No fee schedules, basic unit, relative
values or related listings are included in CPT. The American Medical Association
(AMA) does not directly or indirectly practice medicine or dispense medical
services. The responsibility for the content of this product is with Aetna, Inc.
and no endorsement by the AMA is intended or implied. The AMA disclaims
responsibility for any consequences or liability attributable to or related to
any use, non-use, or interpretation of information contained or not contained in
this product.
This Agreement will terminate upon notice if you violate its terms. The AMA is a
third party beneficiary to this Agreement.
Should the foregoing terms and conditions be acceptable to you, please indicate
your agreement and acceptance by selecting the button labeled "I Accept".
The information contained on this website and the products outlined here may not
reflect product design or product availability in Arizona. Therefore, Arizona
residents, members, employers and brokers must contact Aetna directly or their
employers for information regarding Aetna products and services.
This information is neither an offer of coverage nor medical advice. It is only
a partial, general description of plan or program benefits and does not
constitute a contract. In case of a conflict between your plan documents and
this information, the plan documents will govern.
I accept
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