Meritain Prior Authorization List (2024)

FAQs

Are Aetna and Meritain the same? ›

Meritain Health is a popular insurance provider and is a subsidiary of its parent company, Aetna.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

On your Claims Summary page, you can enter identifying information to search for specific claims. Simply enter the information in the appropriate boxes. You can search for claims based on claim type, claim status, provider name, claim number or dates of service. Then click the Apply button.

Prior authorization—sometimes called preauthorization or precertification—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

Subsidiary of Aetna® and CVS Health®

Access to over 1.6 million providers nationwide, unmatched network discounts and one of the largest pharmacies.

Over 90 percent of our plan sponsors choose to offer the Aetna Choice®​ POS II network, a national network with carrier-level discounts. If you start here, you'll gain access to 1.6 million health care providers nationwide, including over 350,000 behavioral health providers.

How long does prior authorization take? The review typically takes about 14 days. Then, we'll update you and your doctor with a decision.

The Meritain Consumer Directed Health Plan (CDHP) with Health Savings Account (HSA) is a high-deductible health plan administered by Meritain Health. All care, including prescriptions, is subject to the deductible and coinsurance — except for preventive care and prescriptions used to manage certain medical conditions.

A referral is an order from your PCP to see a specialist or receive certain medical services from some providers. Your PCP helps make the decision about whether specialist services are necessary for you. Prior authorization is approval from the health plan before you get a service or fill a prescription.

Prompt claims payment

In 2020, we turned around 95.6 percent of claims within 10 business days. Our payment, financial and procedural accuracy is above 99 percent.

How do I file a claim on Meritain? ›

Log in to your Meritain Health member portal account and click Submit a Claim. Select the patient the claim is for and choose the claim type of Lifestyle Education Reimbursem*nt from the drop-down menu. Step 2: Complete the online form with the applicable information.

If the proposed treatment doesn't meet the threshold for being medically necessary, it won't be reimbursed by the payer. If a provider's office submits a wrong billing code, misspells a name or makes another clerical error, this can result in a denied PA request.

Services That Require Prior Authorization

Examples of services that commonly require prior authorization before being approved include: Diagnostic imaging (such as MRIs, CTs, and PET scans) Durable medical equipment (such as wheelchairs) Rehabilitation (like physical or occupational therapy)

2011: Aetna acquired Prodigy Health Group, parent of third-party administrator Meritain Health.

The CVS-Aetna merger was a horizontal and a vertical merger. In horizontal mergers, two competitors combine, and CVS-Aetna are significant competitors in numerous Medicare Part D geographic markets and also with respect to pharmaceutical benefit management (PBM) services.

Remember, Aetna and Coventry are the same company, so you and your patients may see either name or logo on the communications we send to you.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).