It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. 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. The Braven Health℠ name and symbols are service marks of Braven Health.By clicking on “I Accept”, I acknowledge and accept that:

The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity asĪdministrator of programs and provider relations for all its companies. Products and services are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon Healthcare of New Jersey, Braven Health, and/or Horizon Healthcareĭental, Inc., each an independent licensee of the Blue Cross and Blue Shield Association. To see all available Qualified Health Plan options, go to the New Jersey Health Insurance Marketplace at

This website does not display all Qualified Health Plans This website is operated by Horizon Blue Cross Blue Shield of New Jersey and is not New Jersey’s Health Insurance Marketplace.

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