[PDF] Directory - Aetna Medicare

You can access most outpatient therapy serviceswithout a referral or pre-authorization. However, youshould first consult with Member Services to confirmthat any such outpatient therapy services do notrequire a referral or preauthorization.Behavioral Health Provider Safety DataAvailableFor information regarding our Behavioral Health providernetwork safety data, please go to www.aetna.comand review the quality and patient safety links posted:http://www.aetna.com/docfind/quality.html#jcaho.You may select the quality checks link for detailsregarding our providers’ safety reports.Behavioral Health Prevention ProgramsAetna Behavioral Health offers two preventionprograms for our members: Perinatal DepressionEducation, Screening and Treatment Referral Programalso known as “Mom ’s to Babies DepressionProgram” and Identification and Referral ofAdolescent Members Diagnosed With DepressionWho Also Have Co-morbid Substance Abuse Needs.For more information on either of these preventionprograms and how to use the programs, ask MemberServices for the phone number of your local CareManagement Center.Claims Payment for Non-NetworkProvidersIf your plan provides coverage for services rendered bynon-network providers, you should be aware thatAetna determines the allowable fee for a non-networkprovider by referring to the Original Medicareapproved amount, which is the maximum amountthat Original Medicare allows a provider to accept.Charges by a non-network provider in excess of theMedicare approved amount will not be covered byAetna, nor are they the responsibility of the member.You may be responsible for any charges Aetnadetermines are not covered under your plan, as well asany cost sharing outlined in your plan documents.Technology ReviewAetna reviews new medical technologies, behavioralhealth procedures, pharmaceuticals and devices todetermine which one should be covered by our plans.And we even look at new uses for existingtechnologies to see if they have potential. To reviewthese innovations, we may:■ Study medical research and scientific evidence onthe safety and effectiveness of medicaltechnologies.■ Consider position statements and clinical practiceguidelines from medical and government groups,including the federal Agency for Health careResearch and Quality.■ Seek input from relevant specialists and experts inthe technology.■ Determine whether the technologies areexperimental or investigational.You can find out more on new tests and treatments inour Clinical Policy Bulletins. You can find the bulletinsat www.aetna.com, under the “Members andConsumers” menu.Medically Necessary“Medically necessary" means that the service orsupply is provided by a physician or other health careprovider exercising prudent clinical judgment for thepurpose of preventing, evaluating, diagnosing ortreating an illness, injury or disease or its symptoms,and that provision of the service or supply is:■ In accordance with generally accepted standards ofmedical practice; and■ Clinically appropriate in accordance with generallyaccepted standards of medical practice in terms oftype, frequency, extent, site and duration , andconsidered effective for the illness, injury or disease;and■ Not primarily for the convenience of you, or for thephysician or other health care provider; and■ Not more costly than an alternative service orsequence of services at least as likely to produceequivalent therapeutic or diagnostic results as tothe diagnosis or treatment of the illness, injury ordisease.VI