Aetna, a CVS Health company, provides health insurance to over 34 million members. Aetna prior authorization requirements apply to advanced imaging, many surgical procedures, specialty medications, and certain outpatient services. Aetna uses its own clinical policy bulletins (CPBs) to determine medical necessity.
Aetna providers can submit prior authorization requests through Availity, the Aetna provider portal, or by phone/fax. Availity is the preferred electronic submission method. Aetna also uses the CoverMyMeds platform for pharmacy prior authorizations.
Aetna requires prior authorization based on their Clinical Policy Bulletins (CPBs), which outline evidence-based criteria for covered services. PA is commonly required for advanced imaging, outpatient procedures, specialty drugs, DME, and certain diagnostic tests. Aetna has been expanding electronic PA capabilities in recent years.
Aetna manages imaging prior authorizations through its own utilization management program. Providers must document clinical indications that align with Aetna's CPBs. MRI, CT with contrast, PET scans, and nuclear medicine studies generally require PA. Aetna publishes their imaging PA criteria in their CPBs, which are publicly available.
Reference Aetna's Clinical Policy Bulletins (CPBs) before submitting to ensure your documentation meets their criteria.
Use Availity for faster electronic PA submissions.
Include documentation of conservative treatment trials when required by the CPB.
For pharmacy PAs, CoverMyMeds integration can significantly speed up the process.
Aetna offers a precertification lookup tool to verify which services require PA for a specific member.
Document the specific clinical indication and how it maps to the CPB criteria in your submission.
Greenlight Medical submits prior authorizations directly to Aetna, assembles all required documentation, and tracks status in real time. No portal logins, no phone holds, no fax machines.
See Greenlight in ActionYou can use Aetna's precertification lookup tool on their provider portal or check Availity. Enter the CPT code and member information to see if PA is required. Greenlight Medical automatically checks PA requirements for every order, so your team never has to look this up manually.
Yes, Aetna generally requires prior authorization for MRI studies. The specific requirements are outlined in their Clinical Policy Bulletins. Documentation must demonstrate medical necessity and that appropriate conservative care was attempted where applicable.
Aetna typically provides PA decisions within 2-5 business days for standard requests. Urgent requests are processed within 24-72 hours. Aetna has been investing in automated PA processing, which can provide near-instant decisions for straightforward requests.
CPBs are Aetna's published clinical criteria that define when a service is considered medically necessary. They cover imaging, procedures, medications, and more. Reviewing the relevant CPB before submitting a PA helps ensure your documentation meets Aetna's requirements.