Aetna Better Health of Oklahoma Participating Provider Prior Authorization Requirement Search Tool

Participating Providers: To determine if prior authorization (PA) is required, enter up to six Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes or a CPT group and select SEARCH. Search result definitions:

YES - Prior authorization request is required for this service.
NO - Health plan does not require a prior authorization request for this service.
NON-COV - CPT or HCPCS code entered is not a covered benefit by health plan.
INVALID - CPT or HCPCS code entered was invalid, not found.
EXPIRED - CPT or HCPCS code entered is no longer valid for use by health plan providers.

Exception Detail, Svc Partner Detail - When the Search

symbol is displayed for the code, place your cursor over the symbol to review additional information regarding PA submission or service partner requirements.

General Information/Code Search:

The term Prior Authorization (PA) is the utilization review process used to determine whether the requested service, procedure, medical pharmaceuticals or medical device meets the company’s clinical criteria for coverage.
Benefit exceptions will require a PA. Benefit limits are based on Oklahoma Health Care Authority (OHCA) fiscal year (July 1 to June 30).
The five character codes included in the Aetna Medicaid PA Requirement Search Tool are obtained from Current Procedural Terminology (CPT), copyright 2010 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
The ProPAT authorization tool is NOT “place of service” specific.
If you have any questions about authorization requirements or need help with the Aetna Medicaid PA Requirement Search Tool, contact Aetna Better Health of Oklahoma Provider Relations at 1-844-365-4385.
PA requirement results are valid as of today’s date only. Future changes to CPT or Healthcare Common Procedure Coding System (HCPCS) codes that require PA will be communicated by Aetna Better Health on the home page of Aetna Better Health’s secure web portal.
Benefit coverage may vary by member or may be subject to special conditions. For additional information regarding benefit coverage click here or call 1-844-365-4385.
Search results are not a guarantee of claim payment.
Sterilization - A signed consent form must be completed thirty (30) days prior to procedure but not more than 180 days prior, and the member must be more than twenty-one (21) years old. The form must be submitted with the claim; no prior authorization is required. When a sterilization procedure is performed in conjunction with a C-section, it is considered multiple surgery and a consent form for the sterilization is required.
For Advanced Radiologic Services (CT, MR, PET) or Pain Management please contact eviCore, Inc. Phone 1-888-693-3211. Fax completed authorization form and medical records to 844-822-3862 or 844-82AETNA. Requests can also be submitted via the eviCore portal. Click here to be taken to the eviCore portal.
For Oncology Services, submit treatment plans to NantHealth via their web portal, Eviti Connect, which will expedite clinical review of any chemotherapy, radiation therapy, or supportive medications that require prior authorization. Click here to be taken to the Eviti® Connect portal. Requests can also be submitted by phone at 1-888-482-8057.
For Dental Benefits contact Oklahoma Health Care Authority.
Vision: Vision services are provided by EYEMED. Click here to be taken to the EYEMED portal. Inquiries can also be submitted by phone at 866-939-3633.
For Non-Emergent Transportation Authorizations submit requests to Modivcare. Click here to be taken to the Modivcare portal. Requests can also be submitted by phone at 877-404-4500.
For Hearing Authorizations submit requests to Nations Hearing. Click here to be taken to the Nations Hearing portal. Requests can also be submitted by phone at 877-439-2665.
Pharmacy benefits are managed by the health plan. For Pharmacy Prior Authorization call 844-265-4365 or fax 888-601-8461.

Additional Prior Authorization Information:

All inpatient stays require authorization
Behavioral Health services for Partial Hospitalization, Psychiatric Residential Treatment Facility, Substance Use Disorder (SUD) Residential and Inpatient levels of care require PA. Some outpatient services also require authorization.
Observation level of care does not require an authorization and has a benefit maximum of 48 hours. However, services provided under observation may require prior authorization.
ALL services provided by non-participating providers/practitioners require PA
ALL services provided by out-of-state providers/practitioners greater than 50 miles from the state border require PA

Services NOT Requiring Prior Authorization:

Behavioral Health Crisis Services
Medication Assisted Treatment (MAT)
Programs for Assertive Community Treatment (PACTs)
Behavioral Health Urgent Services
Most office level services do not require pre-authorization. Please verify by submitting the code to confirm and reviewing for any exceptions.
For routine labs performed in an office or outpatient setting
Family Planning
Emergency Services

Enter CPT or HCPCS Code(s)

Select CPT Group:

NOTE: When selecting by CPT group, the results displayed include CPT codes where PA requirements are both Yes and No, as specified on the PA List. To reduce the list of CPT or HCPCS codes to only those requiring PA, please check the box labelled “Include only CPT or HCPCS codes where PA is required?”.

Include only CPT or HCPCS codes where PA is required?