MedicaidPrior AuthHigh impact
Best Practices for Verifying Coverage and Prior Authorization Requirements for Services
Aetna Better Health of Virginia·VA·Prior Authorization
We identified it
Aug 13, 2026
Summary
Aetna Better Health of Virginia has issued best practice guidelines to reduce prior authorization and non-covered service claim denials. The policy establishes a three-step verification process: (1) verify member eligibility and coverage, (2) use ProPat tool to check prior authorization requirements, and (3) confirm the service is covered per DMAS Fee Schedule, with special attention to flag code 999 (non-covered) and IC codes (individual consideration).
Action Required
IMMEDIATE - Billing team must implement mandatory three-step verification process for all Aetna Better Health Virginia claims: (1) Verify member eligibility via 1-800-279-1878 or Availity Provider Portal before service delivery; (2) Use ProPat authorization lookup tool (AetnaBetterHealth.com/virginia/providers/authorizations) to determine if prior authorization is required before claim submission; (3) Consult DMAS Fee Schedule (dmas.virginia.gov) to confirm service is covered, paying specific attention to flag code 999 (indicates non-covered service—do not bill) and IC-marked codes (requires individual consideration). Update all billing workflows, encounter forms, and staff training to incorporate these verification steps. Failure to follow this process will result in increased claim denials. Train front desk, clinical, and billing staff on the ProPat tool and DMAS Fee Schedule lookup function immediately.