Aetna Prior Authorization: Fill & Download for Free

No, it shows a lack of understanding of how the medical review process works inside an insurance company.While medical policies are developed and overseen by the medical director, who is a licensed physician, most claims and coverage determinations are effectively managed (authorized or denied) by nurses who perform the reviews, research the cases, and apply criteria.Complex, unusual, and questionable cases are routinely escalated by the nurses to physician advisors. It’s not unusual to involve multiple clinicians in some cases. In the majority of companies, the medical director has many other duties but personally spends plenty of time on claims, prior authorizations, and appeals, too. The system works very well. Most coverage determinations would have the exact same outcome whether made by nurse reviewers or physicians.

First off, congratulations on taking the first steps towards transition! It can be a challenge (as it seems you have already found), though so can living in the wrong body for 19 years, so I’m sure once you get the ball rolling you’re totally going to kick ass. Based on your question and how you identified I’m going to assume that you’re M2F and have not begun the process, so I apologize if I’m wrong — but for the most part the steps will be the same.Here’s my TLDR answer — go to this website and use their search engine:Database of Medical ProvidersIf you’d like more detailed advice, read on. Sorry, I tend to be thorough.I’ll first talk about the process of finding access to the medical/clinical care, then on to the emotional.untilStep #1 — You will start with hormone replacement therapy (HRT). Hormones will do most of the work as far as transition goes, and people will often put the actual surgery off for a while or even completely because they’re satisfied with their ability to pass while on HRT, not to mention in comparison hormones are pretty affordable (you’re in the right place — in 2014 the state insurance commissioner mandated that all health care insurers in Washington must cover transgender care). HRT management will involve regular visits to the doctor for blood work and monitoring levels, so selecting the right person to do this for you will be important.HRT can be technically be prescribed by any physician, but not all docs are comfortable with it. Bias is probably not a huge issue in Seattle, but discomfort doesn’t necessarily mean they’re biased, it may just mean they don’t feel educated enough on the matter to meet your needs. You will definitely want to find someone that has experience prescribing and managing HRT, especially because they will be able to consult with an endocrinologist on your behalf, they will be knowledgeable on resources for trans people, and they can refer you to other specialists when or if you do decide to move on to surgical stuff.Ideally, the doc you choose works in a clinic specifically geared towards trans care. Database of Medical Providers can offer a list, but here are some suggestions of docs that specifically focus or have knowledge of trans care:Dr. Kevin Hatfield at The Polyclinic Downtown leads a team of specialists in this area. Their website says he’s not currently accepting patients, but you could still call them and ask who else they would suggest. Polyclinic accepts Aetna.Dr. Linda Gromko at Queen Anne Medical Associates (Transgender Care page on their website) accepts Aetna.Peter Shalit MD, Paul Algeo PharmD PA-C, General Internal MedicineNow when I say “accepts Aetna”, that doesn’t necessarily mean it will be covered by your individual insurance plan — see step #2.Step #2 — Call Aetna, have your insurance card ready, and either ask them about coverage for the specific providers you’re interested in, or ask them for a referral to an in-network general physician (this can be family medicine, internal medicine, etc.) that has experience with trans care and HRT. That second option may be hit-or-miss, because the representatives may not know what to do with that or that it’s even something doctors might specialize in. I have Regence so I can’t promise what Aetna will do, but when I called looking for a therapist in my area they asked about any specific needs or areas of focus, then sent me an email with an organized list of in-network practitioners that deal with ADHD and anxiety, their addresses and phone numbers, etc. Docs do list these areas of focus and transgender care will be included on their profiles, but whether the customer service people know that or not is questionable, so coming to them already having found some people will save a lot of time, as well as an awkward conversation. What you’re aiming for is a physician that will only require a small copay (out-of-pocket price per visit, mine is $30). You will still need to ask about coverage of HRT, because that cost is separate from the cost you pay to see the doc.Something to keep in mind (and ask them about) is your deductible, which is the amount of money you have to pay out-of-pocket (such as copay) for your medical expenses before the insurance company starts picking up the bill. The cost of surgery and specialists visit will probably be high enough that may actually pay enough of your own money to meet your deductible and can then expect them to cover what remains, but this isn’t likely during the first year — if your deductible is high enough, you may not reach that point by the time a new year rolls around, even with HRT costs and the cost of doc visits. This is something to consider when thinking about the financial commitment you’ll make, but additionally in some cases it may mean that finding a provider that is in your network doesn’t really matter. For example, my online account with Regence (you should sign up for one on Aetna’s website — even though it doesn’t really provide the information that a representative can, it still provides quick access to info about your policy) allows me to search for providers, find out if they’re in-network or not, and see what my estimated visit cost would be. I found that the therapists they had suggested were about the same cost per visit or sometimes much more expensive than the out-of-network therapists. That is because my policy doesn’t cover therapy, so sticking to their rules doesn’t benefit me. Knowing this may allow you to find providers that are more affordable, but that Aetna did not suggest. The one thing you lose in that case is the fact that the amount you’re paying them is not recognized as going toward meeting your deductible, but in my case I wasn’t going to meet it anyways, so ultimately it made more sense to pay less out-of-pocket.Step #3 — The next step, if you choose, is surgery. Things start to get more complicated here, as there are many separate elements of surgical transition, requiring a slew of different specialists.If you have already established care with an experienced physician, this should be pretty easy, as they will either be part of a pre-existing medical team or will know where to refer you. I definitely would not suggest seeing a specialist without already having a doc that’s managing your HRT, because it would either be insanely expensive, a waste of your time, or both.Some insurance companies and/or policies require you to have a referral from your doctor in order to see a certain specialist, and they will then send a “prior authorization” request to Aetna, which is basically a bullshit bureaucratic requirement where some idiot at the company with no medical knowledge decides whether he agrees with your doctor’s referral or not. It’s really just an attempt on their part to find providers that, qualified or not, won’t cost them as much. You may be able to avoid this frustration by asking your doctor to give you a list of the specialties you will be seen by, then repeating step #2 and asking them to provide names of covered providers in each specialty. You can then bring this list to your doctor, and have them suggest providers from the list that they know and trust. Depending on the policy, some specialty areas aren’t covered regardless, so you may be better off sticking to the ones your doctor already works with, because your care will be much more coordinated that way, however…Cost and insurance coverage deserves another bullet point. Unlike when I said to blow off their in-network rules when they’re probably not going to end up helping you at all with costs anyways, things change when you start talking about expensive specialists and procedures — now there is a greater chance they will end up having to pay, which is why all the hullabaloo with referrals and prior authorizations. There is a greater chance your expenses will rack up to the point of meeting your deductible, or that you will meet your out-of-pocket maximum, another situation where they are forced to foot the remaining cost. Seeing an in-network provider may initially be as pricey as one out-of-network, but you can at least laugh menacingly to yourself with each visit, knowing that you’re inching closer and closer to being able to slap them with the bill.According to their website (here Gender Reassignment Surgery), Aetna considers gender reassignment surgery a medical need, not a cosmetic procedure, as it was once treated. I didn’t have much time to read that page, but that will definitely mean significantly lower costs because they won’t pay a dime for cosmetic procedures.Okay, on to the emotional needs. The aforementioned steps generally apply here as well, but I’ll do the quickie (sort of) version:Step #1 — Do research.If you’re not familiar with the the differences between social workers, therapists, psychologists, and licensed mental health counselors, I suggest you read about them so you know what you’re looking for. You’re not looking for a psychiatrist, because even though they may do some therapy, their primary job is prescribing medications for mental health issues. It would also be worth your time to research different styles of therapy as well (read Different approaches to psychotherapy), because mental health practitioners will use one or a mix of these styles, and some may not sound so great to you.Step #2 — Use search engines, like Database of Medical Providers or one accessed through your Aetna online account, to find a therapist you think might be right for you.Keep in mind that they don’t necessarily need to specialize in trans issues, because ultimately emotions are emotions, and therapy techniques will be the same for problems ranging from OCD to bipolar disorder. But if it is important for you to feel like they know exactly what the fuck you’re going through, make it a priority. Sometimes seeing gender dysphoria (I think that’s what they’re calling it now) or LGBTQ under their list of expertise can provide a guarantee of some comfort and understanding, and since you often don’t get straight to the down-and-dirty emotions until you’ve established a relationship and instead spend the first many visits just venting about the process, having someone that can say more about it than just “how does that make you feeeel?” and won’t need you to educate them on the subject might ensure a stronger connection, which matters a lot in making therapy worth your time.Here are some mental health providers offering therapy or counseling, with expertise in LGBTQ or trans-specific concerns:Home - Seattle Counseling Servicehttp://seattletherapyalliance.com/ - Seattle Therapy Alliance - note the stuff you learned about differences between types of mental health practitioners and their level of education/training — this place is more affordable because many of them are working there to complete final steps toward a degree. Nothing wrong with that, but I personally want someone who has hundreds of hours worth of work with the issues I’m experiencing.Seattle Gay, Lesbian, Bisexual & Transgender Counseling ServicesJennifer Creson Counseling | Seattle, WA - expert in work with individuals in the process of transition. If she’s accepting patients, she would be a valuable consideration.Step #3 — Call Aetna and find out what your policy covers. If you already know names of providers you are interested in, ask if they are in-network, then decide whether it even matters, based on what policy covers. As I stated before, there is a chance that you will end up paying less for someone out-of-network.Step #4 — Before making your decision, compare visit costs between providers, which will be stated on their website, or they will share this with you if you contact them.If visit costs for all providers is going to be too expensive for you to pay out-of-pocket, there are other options for receiving sliding scale or sometimes free counseling. Check their websites for mention of reduced fee opportunities. Free services are usually only offered by government or private organizations and are meant for people in crisis, for instance following a sexual assault, or for people who suffer prolonged and significant trauma. If you can pay something, try to avoid going this route as it won’t be a sustainable option.Step #5 — Contact the provider to make an appointment. They may have you complete some forms, then you’ll have an intake appointment, which is longer than your regular visits will be, and it’s meant to be an opportunity for you to feel out whether you connect with them. Therapists aren’t money hungry. It’s a waste of both your time and theirs if you end up dropping them after 3 visits because you didn’t like them; they want you to be sure this is a relationship you’re willing to put some commitment toward. That doesn’t mean things won’t change and maybe you will change your mind later, which is okay and understandable — but really my point is that you should self-advocate and not settle for the first provider you find, because there are tons out there and many people have to try out 3–4 therapists before finding the right one for them.Step #6 — Keep in mind that a mental health provider is not an adequate substitute for a strong support system. Your relationship with them will at times feel intimate, but at no point does this become a friendship — that is strictly against their practices. Furthermore, the most often you will meet with them is weekly, but more likely it will be bi-weekly, and you need people you can lean on in the interim. If your friends and family are on board and you think they will be able to be there for you when you need it, that’s great. But it’s also nice to find others that understand what you’re going through. Within these groups, you will find friends that you can call at 2 a.m. when your HRT is making you overly emotional, or that can make you feel less isolated when no one knows what you’re going through.Here are links to some support and social groups for trans, genderqueer, etc. etc. individuals:The Emerald City Social ClubWelcome to Ingersoll Gender CenterWashington Gender AllianceTransitioning Guidelines

One note about this dilemma: the electronic health record stores the patient's insurance info, so every health care provider has easy access to the details of what company insurer is involved.However, by the same token, no provider is aware of what actual benefits the name "Aetna" (for example) gives the specific patient. This is because Aetna offers many different plans, and the patient could be in different stages of use with their specific plan (e.g. over or under a limit based on past use). And, coverage will depend on the specific billing codes used which may not even be known before treatment.In terms of who is to blame? While both physician and patient have responsibilities that folks in this thread have named, I think it is very unreasonable for either to be expected to play a real role here. The patient is sick and needs help, and they already provided their insurance card that was entered into the computer system; that should be all they need to do. The doctor went to a decade of schooling to learn how to heal people, and there is a sick person in front of them; they really should focus on healing and not talking with a call center in Arkansas to authorize a treatment with insurance.I say the hospital and insurance company are responsible for fixing the problem. These are the two main parties coordinating care, but they aren't communicating well. The hospital knows the patient insurance info and the house staff roster, and the hospital makes the scheduling decisions (e.g. use of ORs, etc. is done by some chief in his/her capacity as a hospital representative). The insurance decides when they are willing to pay, and therefore has a responsibility to be involved prior to treatment to ensure payment will not be unexpectedly "denied" later.Imagine going to a car wash with a coupon and ordering the $10.99 service. You pay by credit card. Afterwards one of the dryer guys says you owe him personally $3 because he doesn't accept the coupon even though the facility did, and he tried to bill the coupon provider which says wash/dry is included but the coupon provider denied the extra unauthorized charge. Yet he was told to dry that car by the shift manager.The analogy might not be perfect but the car wash really should know this is about to happen, and the coupon provider should also see their coupon system is busted. The car owner and drying guy are kind of stuck in middle (with some responsibility, but less than the other two parties I claim).