Columbia University Health Services

Aetna evaluates and determines the appropriateness of medical care resources utilized by our members. To accomplish these goals, Aetna has developed a comprehensive Patient Management Program. Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal process. Aetna’s patient management staff uses national guidelines and resources to guide the pre-certification, concurrent review, and retrospective review processes.

Pre-Certification
You must obtain Pre-Certification for certain types of care, such as non-emergency surgery, rendered by Non-Preferred Providers to avoid a reduction in benefits paid for that care. To request Pre-Certification, you must call Aetna Student Health.

Such Pre-Certification must be obtained before care is received, or in the case of an emergency admission, procedure, or treatment, within 1 business day after the start of a confinement as a full-time inpatient or the performance of the procedure or treatment, or as soon as reasonably possible.

Concurrent Review
The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review.

Discharge Planning
Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during Pre-Certification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by the member upon discharge from an inpatient stay.

Retrospective Record Review
The purpose of retrospective review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions. Aetna's effort to manage the services provided to members includes the retrospective review of claims submitted for payment, and medical records submitted for potential quality and utilization concerns.