Navigating the complexities of healthcare can be challenging, and understanding your health plan is crucial. As an Aetna US Healthcare member, you have access to a range of services and resources designed to help you make informed decisions about your care and benefits. This guide clarifies key aspects of Aetna member services, focusing on Clinical Policy Bulletins (CPBs) and how they relate to your healthcare journey.
Aetna Clinical Policy Bulletins (CPBs) are developed to assist in the administration of your health plan benefits. It’s important to understand that CPBs are not medical advice. Your healthcare provider is solely responsible for your medical care and treatment. If you have any questions about a CPB related to your health condition or coverage, always discuss it with your doctor or other treating provider.
While CPBs help Aetna manage plan benefits, they are not a complete description of your plan benefits. Instead, CPBs represent Aetna’s assessment of whether certain medical services or supplies are considered medically necessary, experimental, investigational, unproven, or cosmetic. These determinations are based on a thorough review of current clinical evidence. This evidence includes:
- Clinical outcome studies published in peer-reviewed medical literature.
- Regulatory status of medical technologies.
- Evidence-based guidelines from public health and health research agencies.
- Guidelines and positions of leading national health professional organizations.
- Views of practicing physicians in relevant clinical areas.
- Other relevant factors.
Aetna strives for accuracy and relies on reputable sources, but it’s important to note that Aetna is not liable for the content of external information cited in CPBs. The analyses and conclusions within CPBs are Aetna’s opinions, intended to guide coverage decisions and are not meant to defame any provider, product, or service. Aetna reserves the right to update CPBs as clinical information evolves and welcomes feedback for factual corrections.
For administrative purposes, CPBs include standard HIPAA-compliant code sets to facilitate searches and streamline billing and payment for covered services. CPBs are updated regularly with new and revised codes. When submitting claims, it is essential to use the most accurate and current code effective on the date of service. Avoid using nonspecific or unlisted codes whenever possible.
Understanding Your Specific Benefit Plan is Key
It’s crucial to remember that your individual benefit plan document is the ultimate source for determining your coverage. Each plan outlines covered services, exclusions, dollar limits, and other restrictions. Always consult your benefit plan to understand what is covered for you. Just because a CPB deems a service or supply medically necessary, it does not guarantee coverage under your specific Aetna plan. Your plan determines what Aetna will pay for. Some plans may even exclude coverage for services Aetna considers medically necessary. In case of any conflict between a CPB and your benefit plan, your benefit plan always takes precedence.
Furthermore, legal mandates at the state, federal, or CMS level (for Medicare and Medicaid members) can also influence coverage.
For more information on Medicare coverage, you can visit the CMS’s Medicare Coverage Center.
CPBs are continuously updated and subject to change, reflecting the evolving nature of medical knowledge and practice. Given their technical nature, Aetna encourages members to review CPBs with their healthcare providers to fully grasp the policies and how they might apply to their care. If your physician has questions or wishes to discuss a medical necessity determination made based on a CPB, they can request a peer-to-peer review with an Aetna medical director.
While CPBs establish Aetna’s clinical policy guidelines, coverage decisions are made on a case-by-case basis. If you disagree with a coverage decision, Aetna provides a formal appeals process. In certain situations, you may also be eligible for an independent external review of coverage denials related to medical necessity or experimental/investigational status, particularly for services exceeding $500 in member financial responsibility. However, state mandates may take precedence for fully insured and self-funded non-ERISA plans.
You can learn more about Aetna’s external review program at Aetna’s External Review Program.
The five-character codes within CPBs are derived from Current Procedural Terminology (CPT®), copyrighted by the American Medical Association (AMA). CPT codes are used for reporting medical services and procedures. Aetna is responsible for the content of CPBs, and AMA endorsement is neither intended nor implied. The AMA disclaims liability related to the use or interpretation of information within CPBs. For any use of CPT codes outside of Aetna CPBs, refer to the most current CPT manual.
License and U.S. Government Rights
The use of CPT codes within Aetna CPBs is licensed for personal use in Aetna healthcare programs. The AMA holds all rights to CPT. Unauthorized use, including copying, modification, or commercial use, is prohibited. For any other use, licensing must be obtained directly from the AMA.
CPT is considered commercial technical data under U.S. Government regulations, with restricted rights for government use as defined in applicable FAR/DFARS clauses.
Disclaimer of Warranties and Liabilities
CPT is provided “as is” without warranties. The AMA does not practice medicine and disclaims liability for the use or interpretation of information in CPBs. Aetna is responsible for the content of CPBs, and AMA endorsement is not implied.
This agreement is terminable upon violation of its terms, and the AMA is a third-party beneficiary.
Important Information for Arizona Residents
Product information on the Aetna website may not be applicable to Arizona. Arizona residents should contact Aetna directly or their employers for specific product details.
General Disclaimer
This information is for general description only and is not an offer of coverage or medical advice. Your plan documents govern in case of any conflict.
For further assistance with your Aetna Us Healthcare Member Services, please refer to your member portal or contact Aetna directly through the contact information provided on your member ID card.
