Aetna processes standard prior authorization requests within 15 calendar days. Urgent or expedited requests receive a decision within 72 hours. CMS now mandates 72-hour response for expedited PA requests as of January 2026.
Day 1: Submit PA request via Availity or the Aetna provider portal. Days 2-5: Initial review and completeness check. Days 6-15: Clinical review and decision for standard requests. For urgent requests: decision within 72 hours. If approved: authorization number issued, valid for 60-90 days depending on service type. If denied: written notification with denial reason and appeal instructions.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification absent | PA not obtained before service | Submit PA 10+ days before scheduled service |
| CO-50 | Non-covered service | Service not covered under patient's plan | Verify coverage before submitting PA |
| CO-16 | Claim differs from auth | Billed service differs from authorized service | Match CPT codes exactly to authorization |
Appeal denied authorizations within 180 days of the denial notice. Submit through the Aetna provider portal or fax to the number on the denial letter. Include clinical documentation supporting medical necessity. Standard appeal decisions take 30 days. Expedited appeals for urgent care: 72 hours.
Log into the Aetna provider portal or Availity. Search by patient ID and date of service. Status categories: Approved, Denied, Pending Review, or Additional Info Needed.
Under CMS rules, failure to respond within the required timeframe may be treated as an approval for Medicare Advantage plans. For commercial plans, contact Aetna Provider Services to escalate.
Yes, for emergency services and certain urgent situations. Submit within 2 business days of the service with clinical documentation explaining why prospective authorization was not possible.
Altair checks Aetna authorization requirements before you submit and tracks approval status in real time.