Precertification of Medical Benefits
|Precertification is required for hospitalizations and certain outpatient procedures (click here for a current list). When precertification is required, the hospital or your doctor is responsible for calling the Aetna precertification phone number for providers on your ID card.
- If you use an Aetna network provider, your provider is responsible for obtaining necessary precertification for you. Because precertification is the provider’s responsibility, if your provider fails to precertify required services, the provider’s reimbursement will be limited and the provider cannot bill you for those services.
- If you use a non-preferred provider, your provider may precertify for certain services on your behalf. If the provider fails to precertify those services, Aetna will review the medical necessity of those services when the claim is filed. If the service is not medically necessary and is not approved, no benefits will be paid. If the service is medically necessary, benefits will be paid according to the Plan and you will be responsible for the following penalties:
- $400 penalty for failure to precertify inpatient hospital admissions.
- $200 penalty for failure to precertify a skilled nursing facility admission.
For more information, review the Precertification Requirements section of the Plan Booklet.
Preauthorization of Travel Benefits
|If you must travel to receive treatment or medically necessary diagnostic services not available locally, the ASEA Health Trust Plan covers travel expenses and a portion of food and lodging under certain conditions. Non-emergency travel or diagnostic services must be preauthorized to receive treatment under the Medical Plan. In order for the travel expenses to be considered for reimbursement, you and your physician must complete the Travel Preauthorization Application and submit the form before you travel.
- The Medical Plan pays travel and ambulance costs within the contiguous limits of the United States, the State of Alaska and the State of Hawaii.
- Travel is covered and the requirement for preauthorization is waived if you have an emergency condition requiring immediate transfer to a hospital with special facilities for treating your condition.
- Travel is also covered (and a portion of food and lodging) when you need to receive treatment or medically necessary diagnostic services, which are not available in the area where you are located.
If you must travel two or more times for the same condition and the trips are separated by 45 days or more, you must submit another Travel Preauthorization Application.
For more information on Preauthorization requirements for travel, refer to the Preauthorization Requirements section of the Plan Booklet.