Treating providers are solely responsible for medical advice and treatment of members. 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). For example, if you have a $1000 deductible, you . CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 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. This plan carries a high deductible ($1,500 for individuals, $3,000 for family). For those plans, out-of-network care is covered only in an emergency. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. NOTE: Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. You pay your plans copayments, coinsurance and deductibles for your network level of benefits. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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). 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. 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. 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. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. 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. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. Applicable FARS/DFARS apply. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. You must meet it before the plan pays benefits (except for in-network preventive care and preventive generic drugs). A deductible is the amount you pay out-of-pocket for covered services before your health plan kicks in. 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. CPT only Copyright 2020 American Medical Association. 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. New and revised codes are added to the CPBs as they are updated. 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. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. You have this coverage while you are near your home or traveling. The information on this page is for plans that offer both network and . All services deemed "never effective" are excluded from coverage. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 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. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. 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). Unlisted, unspecified and nonspecific codes should be avoided. 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. 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. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. You pay your coinsurance or copay along with your deductible. 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. Your benefits plan determines coverage. An example of how it works: Courtney, 43, is a single lawyer who just bought her first home, a condo in Midtown Atlanta. 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. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. 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. 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 member's benefit plan determines coverage. Otherwise, you are responsible for the full cost of any care you receive out of network. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. 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. All Rights Reserved. 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. 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. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Applicable FARS/DFARS apply. You are covered for emergency care. Please complete the form, or call Member Services to give us the information over the phone. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. A health insurance deductible is a specified amount or capped limit you must pay first before your insurance will begin paying your medical costs. 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. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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