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. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. You pay your coinsurance or copay along with your deductible. How Deductibles, Coinsurance, Copays & Premiums Work - Aetna For those plans, out-of-network care is covered only in an emergency. She loves that her building has a gym and pool because she likes to stay in shape. How Do Health Deductibles Work? No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. NOTE: Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. Unlisted, unspecified and nonspecific codes should be avoided. 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. You are covered for emergency care. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 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 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 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. Please complete the form, or call Member Services to give us the information over the phone. The information on this page is for plans that offer both network and . An example of how it works: Courtney, 43, is a single lawyer who just bought her first home, a condo in Midtown Atlanta. All services deemed "never effective" are excluded from coverage. Treating providers are solely responsible for medical advice and treatment of members. Applicable FARS/DFARS apply. When you need emergency care (for example, due to a heart attack or car accident), go to any doctor, walk-in clinic, urgent care center or emergency room. 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. You must meet it before the plan pays benefits (except for in-network preventive care and preventive generic drugs). In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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 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. , Medicare-based rates, which are determined and maintained by the government, Reasonable,, usual and customary and prevailing charges, which are obtained from a database of provider charges. A health insurance deductible is a specified amount or capped limit you must pay first before your insurance will begin paying your medical costs. 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. You pay your plans copayments, coinsurance and deductibles for your network level of benefits. 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). A deductible is the amount you pay out-of-pocket for covered services before your health plan kicks in. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. This plan carries a high deductible ($1,500 for individuals, $3,000 for family). You have this coverage while you are near your home or traveling. CPT only Copyright 2020 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. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. 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). ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. CPT is a registered trademark of the American Medical Association. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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). 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). Some plans do not offer any out-of-network benefits. 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. 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. For example, if you have a $1000 deductible, you . Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Otherwise, you are responsible for the full cost of any care you receive out of network. Aetna High Deductible Health Plan - PublicWeb Your benefits plan determines coverage. When you have no choice, we will pay the bill as if you got care in network. 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. 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. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. 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. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. New and revised codes are added to the CPBs as they are updated. Well review the information when the claim comes in. 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. 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. That includes students who are away at school. 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. 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. 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). All Rights Reserved. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. The member's benefit plan determines coverage. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. Applicable FARS/DFARS apply. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. 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. 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. Treating providers are solely responsible for dental advice and treatment of members. Network & Out-of-Network Care - Aetna | Benefits, Coverage & Costs Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. When billing, you must use the most appropriate code as of the effective date of the submission. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Visit the secure website, available through www.aetna.com, for more information. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 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