Aetna NPL, Clinical Payment and Coding Policy Changes

March 2018 ~

Effective July 1, Aetna will implement changes to its clinical payment and coding policy for observation services, as well as several changes to its National Precertification List (NPL).

These changes are as follows:

Clinical Payment and Coding Policy Changes

Policy: Observation policy

Effective Date: July 1, 2018

Observation services are the use of a bed and periodic monitoring. It consists of short-term treatment by a hospital’s nursing or other staff. The use of the observation treatment evaluates a patient’s condition to determine the need for possible inpatient admission.

Since 2015, observation stays greater than 24 hours required notification – if notification was not submitted, a late notification penalty would be applied. As of February 1, 2018, for all states Aetna no longer applies a late notification penalty to the provider’s facility.

Update: Effective July 1, 2018, Aetna will implement the following change its observation policy:

  • Prior-notification will no longer be required for observation greater than 24 hours.
  • Observation services that extend beyond 48 hours will no longer be covered.

NPL Precertification Changes

  • Precertification will be required for Calcitonin Gene-Related Peptide (CGRP) receptor inhibitors
  • Precertification will be required for the following new-to-market drugs:
    • Yescarta (axicabtagene ciloleucel; chimeric antigen receptor T-cell therapy drug class) – precertification effective January 2, 2018.
    • Durolane (hyaluronic acid; viscosupplements drug class) – precertification effective February 2, 2018.
    • Fasenra (benralizumab; respiratory injectables drug class) – precertification effective February 9, 2018.
    • Mepsevii (vestronidase alfa-vjbk; enzyme replacement drug class) – precertification effective February 9, 2018.
  • Precertification will not be required for the following:
    • Anti-emetic drugs/medical injectables, including Emend IV (fosaprepitant dimeglumine)
    • Observation stays more than 24 hours (for more information, see the observation policy entry in the policy chart)
    • Power Morcellator

Aetna encourages providers to submit precertification requests at least two weeks before the scheduled services.



Source(s): Aetna OfficeLink Updates All Regions;