Prior authorization (approval) is required for certain procedures, programs, and drugs. Aetna handles prior authorization for the Alaska HERE Plan.
Who is responsible for getting prior authorization?
- Your in-network providers are responsible for getting prior authorization from Aetna. This is a great reason to use in-network providers.
- If you go to an out-of-network provider, you’re responsible for making sure your provider gets prior authorization from Aetna before you receive care.
What services need prior authorization?
The following services require prior authorization. The list may change from time to time. Call 844-427-8501 for the most up-to-date information.
Prior Authorization List
- Inpatient admissions (except hospice)
- Osseointegrated implant
- Ambulance by plane
- Osteochondral allograft/knee
- Autologous chondrocyte implantation
- Proton beam radiotherapy
- Chiara malformation decompression surgery
- Reconstructive or other procedures that may be considered cosmetic
- Coverage at an in-network benefit level for out-of-network provider/facility (excludes emergent services)
- Shoulder Arthroplasty including revision procedures
- Spinal procedures
- Dorsal column (lumbar) neurostimulators; trial or implantation
- Uvulopalatopharyngoplasty, including laser-assisted procedures
- Endoscopic nasal balloon dilation procedures
- Ventricular assist devices
- Functional endoscopic sinus surgery (FESS)
- Video electroencephalograph (EEG)
- Gender reassignment surgery
- Whole exome sequencing
- Hip surgery to repair impingement syndrome
- Applied behavioral analysis (ABA)
- Hyperbaric oxygen therapy
- Lower limb prosthetics, such as microprocessor-controlled lower limb prosthetics
- Partial hospitalization programs (PHPs)
- Non-participating freestanding ambulatory surgical facility services, when referred by a participating provider
- Residential treatment center (RTC) admissions
- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint
- Transcranial magnetic stimulation (TMS)
- Drugs and medical injectables (medications administered by or supervised by a provider) paid by the medical plan
How can providers submit prior authorization requests?
Your providers may submit most prior authorization requests electronically to Aetna through the secure website or using your Electronic Medical Record (EMR) system portal.