![]() ![]() 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. 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. An emergency room copay does not apply when you are admitted for an overnight hospital stay.īy clicking on “I Accept”, I acknowledge and accept that:.You are responsible for any emergency room copay.Any services you receive must be covered under the terms of your Aetna plan. ![]() When seeking emergency care, please note that: In other cases, you should notify your primary care doctor and Aetna within 48 hours of an emergency.If you are admitted to an inpatient facility, you should immediately notify your primary care doctor and Aetna.You should seek immediate treatment for any illness or injury that would be considered an emergency, or for the care of any urgent problem.Remember that urgently needed care is covered while you are traveling outside of your local Aetna service area.If an emergency happens when you’re traveling away from home: Please note that all follow-up care should be coordinated through your primary care doctor.Your primary care doctor knows your medical history and is also responsible for coordinating your health care. Once an emergency facility has stabilized your condition, their staff members should try to contact your primary care doctor.In all cases, you should contact your primary care doctor as soon as possible after receiving treatment. If possible, you should also call your primary care doctor. Call your local emergency hotline ( 911) or go to the nearest emergency facility. ![]()
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