Aetna Prior Authorization Requirements
Aetna Prior Authorization Requirements: Overview
Aetna requires prior authorization for many procedures and imaging services. Pre-service decisions must be made within 15 days; post-service within 30 days. Failure to respond within deadline results in deemed approval per ERISA. Submit via aetna.com (Availity-integrated) or phone. Appeals must be filed within 180 days of denial.
Key Requirements
- Review Aetna Medical Policy: Check the plan's medical policy to determine if the specific service or procedure requires pre-authorization. Some routine services do not require PA.
- Gather Clinical Documentation: Provide diagnosis code (ICD-10), procedure code (CPT/HCPCS), clinical rationale, medical records, and any specialist recommendations.
- Submit Before Service Delivery: Submit pre-service authorization before the patient receives the service to avoid denial and claim rejection.
- Confirm Receipt: Obtain a confirmation number or reference ID when submitting. Phone submissions must be followed by written confirmation within 48 hours.
- Document Approval Terms: Authorization approval includes dates, service limits (visit count, duration), and any medical necessity conditions or limitations.
Timeline & Process
Step 1: Verify Authorization Need . Check Aetna's provider manual or portal for the service. Determine if pre-authorization is required.
Step 2: Gather Documentation . Collect clinical notes, test results, diagnosis codes, and procedure codes. Prepare a brief clinical justification.
Step 3: Submit Request . Use aetna.com portal (recommended) or call Aetna's PA line. Include member ID, NPI, date of service, and clinical summary.
Step 4: Receive Decision . Pre-service: 15 calendar days. Post-service: 30 days. Aetna sends approval or denial notice with authorization number (if approved) or appeal instructions (if denied).
Aetna Prior Authorization Timelines
| Decision Type | Timeline | When to Use |
|---|---|---|
| Pre-Service (Routine) | 15 calendar days | Planned/elective procedures submitted before service delivery |
| Pre-Service (Expedited) | 72 hours | Urgent procedures where 15-day delay poses risk to health |
| Post-Service | 30 calendar days | Services already rendered; used for emergency or stat procedures |
| Deemed Approval | Automatic if no response | Aetna fails to respond within required deadline; request is approved |
Appeal Process
File appeal within 180 days with supporting clinical documentation addressing the denial reason. Aetna conducts second review within 60 days. If both internal reviews fail, escalate to external review (independent medical review) for medical necessity disputes.
Common Questions
How long does Aetna take to approve a prior authorization?
Pre-service (before service delivery): 15 calendar days. Post-service (after service delivery): 30 calendar days. Failure to respond within deadline results in deemed approval per ERISA.
Where do I submit Aetna prior authorization requests?
Use aetna.com (Availity-integrated portal) for online submission, or call Aetna's prior authorization phone line. Phone submissions must be confirmed in writing within 48 hours.
How long do I have to appeal an Aetna PA denial?
180 days from the denial date. Submit an appeal with supporting clinical documentation to Aetna's appeals department. Second review must be completed within 60 days.
Altair checks Aetna requirements before submission . flagging missing authorizations and coding mismatches in real time. See how Altair works.
This reference is for informational purposes. Payer policies change frequently. Always verify against Aetna's current provider documentation. Last updated: 2026-03-16.
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