Summary Plan Description

Precertification

The plan requires precertification for certain medical services. Precertification is the process of determining in advance whether a procedure, treatment or service is medically necessary. Precertification also helps confirm patients are covered for certain tests and procedures before the test or procedure is performed or before the patient is admitted into a hospital. The precertification process confirms the procedure meets medical necessity criteria.

Precertification By Network Providers

If you use a network provider, precertification is done by the provider. If the network provider does not obtain the required precertification, benefits are not provided by the plan if the services are rendered. In addition, the participant and the patient are exempt from any financial liability for the applicable service(s), unless they agreed otherwise with the provider.

Precertification By Non-Network Providers

If a non-network provider is used, then you, the patient, or the provider must request precertification. If precertification is not obtained and it is determined that the service was not medically necessary, then no benefits will be provided and you will be financially responsible for 100 percent of the related services. If precertification is not obtained, but it is subsequently determined that the service was medically necessary and covered, then the following penalty applies:

  • $50 is deducted from the room and board maximum allowable fee for each day of inpatient care, up to a maximum of $250. The penalty does not apply if the claim is for urgent care, where the delay in treatment could: seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function; or subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

To precertify non-network provider services, your provider must call Aetna at (888) 632-3862.

Services Requiring Precertification

The following are examples of services requiring precertification with Aetna at (888) 632-3862:

  • Air transports (fixed wing)
  • Applied behavioral analysis (ABA)
  • Artificial limbs
  • Bariatric surgery
  • Electroconvulsive therapy (ECT)
  • Erectile dysfunction
  • Gender reassignment surgery
  • Hospice care
  • Infused or injectable drugs
  • Inpatient hospital admissions (unless the patient is covered by Medicare)
  • Inpatient rehabilitation admissions
  • Intensive outpatient, partial day or residential treatment
  • Kidney dialysis
  • Organ transplants
  • Orthognathic surgery
  • Prosthetic devices
  • Proton beam therapy
  • Reconstructive surgery
  • Skilled nursing facility services and supplies
  • Spinal procedures
  • Ventricular assist devices (VAD)

The following services require precertification with Carpenters Trusts at (800) 552-0635:

  • Durable medical equipment
  • Home health care
  • Home infusion therapy

For questions regarding whether a service or supply requires precertification, have your provider contact Carpenters Trusts at (800) 552-0635 or Aetna at (888) 632-3862.