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.Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. 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. 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. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. That means you have to pay for the last 2 visits.By clicking on “I Accept”, I acknowledge and accept that:.You visit your physical therapist 22 times.Your health plan covers up to 20 physical therapy visits.This is called an annual limit, which helps to decrease costs by keeping rates reasonable and fair for all members. Your health plan will cover up to a certain amount for certain procedures, medical services and tests. The amount you pay out-of-pocket for your coinsurance is $90.If you've met your annual $4,000 deductible, your health plan will start contributing to your medical costs based on your coinsurance. Let's say you break a bone in your foot and need an X-ray. Example #2: Coinsurance After You've Met Your Deductible You are once again responsible for the $4,000 deductible and 30% coinsurance for that year. Whenever the next plan year begins, your coinsurance and deductible reset. When you've paid $5,000 out of your pocket toward your medical costs, your plan covers 100% of your costs until your "plan year" renews.After you pay the $4,000 deductible, your health plan covers 70% of the costs, and you pay the other 30%.You must pay $4,000 toward your covered medical costs before your health plan begins to cover costs.Example #1: Deductibles, Coinsurance and Out-of-Pocket Maximum Here are a few examples of how deductibles, coinsurance and maximum limits work together. Once you understand the different parts of your health insurance costs you’ll want to know how these work together and what your out-of-pocket costs may be.
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