IQVIA Benefits Handbook
PRE-CERTIFICATION
In-Network
Certain in-network services, such as hospital admissions and select outpatient services require pre-certification. You must obtain pre-certification from Aetna or Kaiser before you receive care for these services. Your network provider will obtain the necessary pre-certifications for you. If you are using out-of-network providers, you are responsible for the pre-certification, and you will incur a financial penalty if you do not obtain the pre-certification.
You may call Aetna or Kaiser for a detailed list of services. The list may change periodically.
Your network provider will also contact Aetna or Kaiser if a maternity stay will exceed 48 hours for the mother and newborn child following a vaginal delivery, or 96 hours for the mother and newborn child following a cesarean section delivery.
Out-of-Network
Certain out-of-network services, such as hospital admissions and select outpatient services require pre-certification. To have your treatment pre-certified, you must call Aetna or Kaiser prior to receiving treatment. If you don't, your benefits may be reduced or denied.
If you have to be admitted to a hospital due to an emergency, you must call Aetna or Kaiser before you're admitted or as soon as reasonably possible.
Services Requiring Pre-Certification
Inpatient Settings
- All inpatient admissions and non-obstetric observations stays such as:
- Acute hospitals
- Hospice care
- Long-term care facilities
- Rehabilitation facilities
- Skilled nursing facilities
- Transfers between inpatient facilities
- Cochlear device and/or implantation.
- Cosmetic procedures.
- Experimental and investigational procedures.
- Gender reassignment surgery.
- Interventional pain management (e.g., implantable infusion pumps, spinal and peripheral nerve stimulators, spine injections)
- Major joint surgeries (hip, knee, shoulder)
- Maternity stays longer than 48 hours (vaginal delivery) or 96 hours (Cesarean section).
- Musculoskeletal services, including major joint surgeries (hip, knee, shoulder) and interventional pain management (e.g., implantable infusion pumps, spinal and peripheral nerve stimulators, spine injections).
- Observation stays more than 24 hours.
- Power morcellation with uterine myomectomy, with hysterectomy or for removal of uterine fibroids.
Outpatient Settings
- Behavioral health services requiring precertification/authorization including:
- Applied behavior analysis (ABA)
- Inpatient admissions
- Intensive outpatient programs (IOPs)
- Neuropsychological testing
- Outpatient detoxification
- Partial hospitalization programs (PHPs)
- Psychological testing
- Residential treatment center (RTC) admissions
- Transcranial magnetic stimulation (TMS)
- Certain imaging services.
- Certain outpatient surgical procedures.
- Certain prescription and injectable drugs (specific listing of codes).
- Chemotherapy for cancer diagnosis.
- Chiropractic care.
- Cosmetic or reconstructive procedures.
- Diagnostic cardiology.
- Dialysis (when request is initiated by a participating provider, and dialysis to be performed at a non-participating facility).
- Durable medical equipment (specific listing of codes).
- External prosthetic appliances, (specific listing of codes).
- Genetic testing.
- High-tech radiology (MRI, CAT scans, PET scans).
- Home health care/home infusion therapy.
- Hyperbaric oxygen therapy.
- Infertility program.
- Infertility treatment.
- Mental health or substance abuse services.
- Musculoskeletal services, including major joint surgeries (hip, knee, shoulder) and interventional pain management (e.g., implantable infusion pumps, spinal and peripheral nerve stimulators, spine injections).
- National Medical Excellence Program®.
- Occupational therapy.
- Pain management.
- Physical therapy.
- Private duty nursing.
- Radiation therapy.
- Requests for services provided by a non-participating provider to be covered at in-network level.
- Sleep studies.
- Speech therapy.
- Ventricular assist devices.
- Video electroencephalograph (EEG).
Additional Services