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). 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. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Otherwise, you are responsible for the full cost of any care you receive out of network. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. 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). 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. Since Clinical Policy Bulletins (CPBs) 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. CPT is a registered trademark of the American Medical Association. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. 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. You are covered for emergency care. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. 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. For those plans, out-of-network care is covered only in an emergency. 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. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. You pay your coinsurance or copay along with your deductible. Your benefits plan determines coverage. A health insurance deductible is a specified amount or capped limit you must pay first before your insurance will begin paying your medical costs. 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. The member's benefit plan determines coverage. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. All Rights Reserved. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. A deductible is the amount you pay out-of-pocket for covered services before your health plan kicks in. When you have no choice, we will pay the bill as if you got care in network. 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. NOTE: Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the plan year. 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. 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 five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. 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. Well review the information when the claim comes in. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. All services deemed "never effective" are excluded from coverage. When billing, you must use the most appropriate code as of the effective date of the submission. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. You must meet it before the plan pays benefits (except for in-network preventive care and preventive generic drugs). For example, if you have a $1000 deductible, you . 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. Some plans do not offer any out-of-network benefits. CPT only Copyright 2020 American Medical Association. 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). Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 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. Unlisted, unspecified and nonspecific codes should be avoided. Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. 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. , Medicare-based rates, which are determined and maintained by the government, Reasonable,, usual and customary and prevailing charges, which are obtained from a database of provider charges. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. 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. Treating providers are solely responsible for medical advice and treatment of members. Visit the secure website, available through www.aetna.com, for more information. 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. 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. This plan carries a high deductible ($1,500 for individuals, $3,000 for family). If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. 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. 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. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. Applicable FARS/DFARS apply. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. 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. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Please complete the form, or call Member Services to give us the information over the phone. That includes students who are away at school. 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. An example of how it works: Courtney, 43, is a single lawyer who just bought her first home, a condo in Midtown Atlanta. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The information on this page is for plans that offer both network and . ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. New and revised codes are added to the CPBs as they are updated. You pay your plans copayments, coinsurance and deductibles for your network level of benefits. You have this coverage while you are near your home or traveling. She loves that her building has a gym and pool because she likes to stay in shape. Treating providers are solely responsible for dental advice and treatment of members. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. 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). 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. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. 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