Preauthorization
If you see a network provider, he/she will obtain preauthorization for your care as required by Aetna. In this case, benefits will be paid according to plan provisions and limits. Aetna will confirm the preauthorization in writing. It will be valid for three months, if your condition doesn't change.
If you see an out-of-network provider, you must call Aetna for preauthorization or ask your physician to call Aetna on your behalf. You may then call Aetna to see if your physician followed through on your behalf.
If you see an out-of-network provider, you must obtain preauthorization from Aetna for the following covered services:
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anorexiants for treatment of attention deficit disorder or narcolepsy;
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durable medical equipment;
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growth hormones (billed through Aetna);
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home health care;
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hospice care;
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injectable prescription drugs, with certain exceptions such as insulin, Depo-Provera and some others (billed through Aetna);
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inpatient chemical dependency treatment;
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inpatient hospital care, other than for most stays in connection with childbirth;
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inpatient mental health care;
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inpatient neurodevelopmental therapy for children age six and younger;
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obesity surgery or other procedures, treatment or services, such as gastric intestinal bypass surgery (preauthorization requires that the procedure is medically necessary and that a physician-supervised weight management and exercise program has been successfully completed);
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orthognathic surgeries (to correct jaw abnormalities or malocclusions when medically necessary);
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skilled nursing facility care;
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TMJ disorders; and
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transplants.
Whether you see a network or an out-of-network provider, Aetna must be notified at least seven days before you have surgery or are admitted to a hospital on a non-emergency basis, except for childbirth. Before your admission, be sure to confirm with the hospital that your stay has been preauthorized.
You must call Aetna within 48 hours from the beginning of your admission, or as soon as reasonably possible, for:
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accidents;
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emergencies, including detoxification;
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involuntary commitment to a Washington State mental hospital; and
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maternity admissions.
To obtain preauthorization for non-emergency care or to obtain certification afterward, ask your physician to contact Aetna.
When calling Aetna, be prepared to supply these details:
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admission date;
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diagnosis or surgery;
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employer name (King County);
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employee name and unique identifying number assigned by KingCareSM;
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hospital name and address or phone number;
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patient name, address and birth date;
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physician name and address or phone number; and
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proposed treatment plan, including length of stay and discharge planning needs.
If your care isn't preauthorized as just described and Aetna determines that your care wasn't medically necessary, KingCareSM may pay only a portion of the charges or none at all.
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