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  • Aetna Prior Auth Form

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T be completed and legible for Precertification Review) Please indicate: Start of treatment, Start Date: / / Continuation of therapy, date of last treatment: Precertification Requested By: Phone: / / Fax: A. PATIENT INFORMATION First Name: Address: Home Phone: Last Name: City: Work Phone: Patient Current Weight: lbs or DOB: State: E-mail: Cell Phone: kgs Patient Height: inches or cms ZIP: Allergies: B. INSURANCE INFORMATION Aetna Member ID #: Group #: Insured: Medicare:.

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All Aetna Medicare Advantage plan members will have 12-digit member ID numbers beginning with “10.” We will no longer use the “ME” prefix for Medicare Advantage plans after that date. Consol Energy will transition from ID numbers beginning with “ME” to those beginning with “10” on April 1, 2022.

Some procedures (For instance, an MRI, CAT scan or surgery.) need approval in advance. Your doctor can ask for this approval up to six months ahead of time. You can share a copy of this guide with your doctor.

Insurance companies often will agree to cover MRIs if patients obtain pre-approval for the imaging. This process, called prior authorization, entails giving the insurer additional information about why the doctor has prescribed the scan and what circumstances, such as an injury, led to the order.

The prior authorization process helps ensure that you are receiving quality, effective, safe, and timely care that is medically necessary. All decisions are backed by the latest scientific evidence and our board-certified medical directors.

Aetna Better Health® of California requires prior authorization for select acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services. A current list of the services that require authorization is available on ProPAT, our online prior authorization search tool.

Aetna considers annual low-dose computed tomography (LDCT) scanning, also known as spiral CT or helical CT scanning, medically necessary for current or former smokers ages 50 to 80 years with a 20 pack-year or more smoking history and, if a former smoker, has quit within the past 15 years.

Medical Necessity Aetna considers magnetic resonance imaging (MRI) medically necessary for appropriate indications without regard to the field strength or configuration of the MRI unit. Aetna considers intermediate and low field strength MRI units to be an acceptable alternative to standard full strength MRI units.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232