Blog

Getting Prior Authorization for Dificid with Aetna Made Simple

Getting prior authorization for medications can feel like stepping into a maze, especially when you’re dealing with specialized medications like Dificid (fidaxomicin) and insurers like Aetna. For healthcare providers, each patient is unique, and ensuring they get the right medication shouldn’t be a barrier—it should be a priority. But as you may know, getting prior authorization often requires jumping through several hoops.

So let’s break it down together, step-by-step, to make this process as smooth as possible for you, your team, and ultimately, your patients. Whether you’re handling this for the first time or simply looking for some tips to speed things up, we’ll cover what you need to know about Aetna, Dificid, and the prior authorization process, from forms to follow-ups.

Insurance Company Overview

Aetna is a well-known insurer with a wide range of plans that support individuals, families, and employers. Like other insurers, Aetna requires prior authorization for many medications to ensure they’re medically necessary and used appropriately. With Aetna, requirements can vary between plans, so if you have patients covered by Aetna, it’s worth familiarizing yourself with the specifics of their policies, especially when it comes to high-cost or specialized drugs like Dificid.

Why Dificid Requires Prior Authorization?

Dificid (fidaxomicin) is a targeted antibiotic used to treat Clostridium difficile-associated diarrhea (CDAD), which can be a serious and recurring infection for many patients. Because of its specialized function and cost, Aetna reviews each request for Dificid carefully to make sure it meets their criteria. From Aetna’s perspective, this process controls costs while ensuring that medications are used where they’re truly needed. From your perspective as a healthcare provider, understanding the reasoning behind these steps can help you plan your approach to secure the approval your patients need.

Step-by-Step Process for Obtaining Prior Authorization for Dificid 

Getting authorization can feel time-consuming, but breaking it into manageable steps can help move things along. Here’s a streamlined approach you can take with Aetna:

Step 1:Discuss Treatment Options with the Patient’s Needs in Mind

First, consult thoroughly with your patient to determine if Dificid is indeed the best choice for their case of CDAD. For patients with recurring or severe C. difficile infections, Dificid’s targeted approach might be ideal, especially when other antibiotics haven’t been effective. Once you confirm that Dificid is the best option, you’re ready to move forward with the authorization.

Step 2:Start with the Right Documentation

For Aetna’s prior authorization, you’ll need to complete their specific authorization form, available through Aetna’s website or electronic portal. Your documentation should be as comprehensive as possible, detailing your patient’s diagnosis, previous treatments, and the reasons Dificid is necessary. This extra detail can make all the difference in ensuring your application is complete and reduces the chance of delays.

What to include in the documentation:

• • Diagnosis – Specify that the patient has Clostridium difficile-associated diarrhea.
  • Previous Treatments – List any other antibiotics or treatments that have been attempted, along with their results.
  • Medical Rationale – Explain why Dificid is necessary for the patient, focusing on its benefits for their condition.

Step 3:Submit the Request Through Aetna’s Systems

Aetna allows prior authorization submissions either by fax or through their electronic prior authorization system. Using their electronic system, if possible, can reduce processing time and gives you a trackable way to monitor progress. Be sure to double-check that all required fields are filled out and any supporting documents are attached before submission.

Step 4:Allow Time for Aetna’s Review Process

Aetna typically reviews prior authorization requests within about 14 days, though this may vary depending on the case’s complexity and any missing information. During this period, Aetna’s clinical team evaluates the request, cross-checking against their criteria, which usually includes verifying the CDAD diagnosis and checking previous treatments.

If the review extends past the standard timeframe, don’t hesitate to follow up. Aetna’s customer service can provide updates and may expedite the process if there are unusual delays.

Step 5:Receive the Decision and Next Steps

After review, Aetna will send their decision to you and your patient. Here’s what to do in each case:

• • If Approved: Notify your patient and guide them through filling the prescription.
  • If Denied: The denial letter will explain why the request wasn’t approved and provide instructions on how to file an appeal. Reviewing this with the patient may help in gathering additional supporting information to strengthen the case on appeal.

ICD and CPT Codes Explained

One thing to remember in the prior authorization process is the role of ICD and CPT codes. These codes may seem straightforward, but using the correct ones can be critical to a successful application.

• ICD Codes: For Dificid, you’ll likely use ICD-10 code A04.7 for Clostridium difficile-associated diarrhea. Including this code helps Aetna quickly understand the diagnosis.
• CPT Codes: Dificid itself doesn’t have a specific CPT code since it’s a medication, but if there are any relevant procedures or services provided in association with this treatment, make sure to include the right CPT codes in your documentation.

Frequently Asked Questions (FAQs)

How long does Aetna’s prior authorization process usually take?

The standard timeframe is about 14 days, though it may vary. Starting the process early helps prevent any gaps in treatment.

What if the prior authorization is denied?

If Aetna denies the request, you have the right to appeal. Work with your patient to gather any additional information that could support the need for Dificid. Providing Aetna with a detailed appeal letter can help clarify the unique aspects of your patient’s condition and why Dificid is necessary.

Can I start the patient on Dificid while waiting for approval?

Generally, it’s recommended to wait until authorization is approved to avoid potential out-of-pocket costs. In some cases, you may find other temporary treatments or strategies while waiting for the decision.

What Did We Learn?

The prior authorization process is crucial for healthcare providers to ensure patients receive the necessary care without unnecessary delays. Clear, complete documentation is essential in this process, starting with the right documentation, accurately submitting it, and following up. Sharing insights on the process can be beneficial for those new to it. Staffingly, Inc. offers services like Insurance Verification, Prior Authorization, Virtual Medical Receptionists, Telemedicine Services, Medical Data Entry, and Medical Coding to reduce administrative workload and save costs. Partnering with Staffingly not only reduces the team’s workload but also saves up to 70% on staffing costs. With 24/7 support, healthcare providers can always have access to a team that can keep things moving even after hours.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of the prior authorization process. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com