Pre-Denial Process for Urgent Auth Requests

www.aetnabetterhealth.com/ohio

November 20, 2018

Dear Provider,

Recently, Aetna Better Health of Ohio implemented a change to our pre-denial notice that included language on the peer-to-peer opportunity. We understand we made the change very quickly and without prior notice. We apologize for the challenge and current frustration this change has caused.

The change in our pre-denial notification primarily affects expedited pre-service requests. We determined that in the case of a communicated denial, the proposed follow-up time for a peer-to-peer discussion was inconsistent with our policy. Our policy language for Concurrent Review reads as follows: "Peer-to-peer review for MMP Duals program Concurrent Review (including LTACH, SNF, IP Rehab and Acute Hospital to Hospital transfers) is only available prior to a denial of coverage determination."

In Ohio, we must finalize and communicate in writing our denials for expedited requests within 48 hours. After you have received our notice to participate in a peer-to-peer discussion, and a decision has been determined that you do not agree with, then your next step will be to follow the appeal process. A discussion can occur after the denial has been communicated, but that discussion cannot result in a re-opening of the request.

Please be reminded that any denial may still be appealed through the required process for pre-service appeals.

We again apologize for the inconvenience for the immediate change in the pre-denial communication. We will continue to work towards building a collaborative partnership with you, and are committed to improving our timing and communications to all of you when conditions require a change in our processes.

Sincerely,

Provider Services

Aetna Better Health of Ohio