Network Information

The Student Medical Plan, subject to the outlined benefits, limits and exclusions, protects the student during the term for which the fee has been paid. The Plan reserves the right to coordinate benefits with any other medical coverage.

Participants of the Student Medical Plan are encouraged to access a national network of Preferred Providers in the Aetna network. Participants may realize substantial savings by utilizing Preferred Providers.

A complete listing of Participating Providers is available through the internet by accessing Aetna's DocFind® Service. Click on Find Your School and select Case Western Reserve University from the list. Additionally, information regarding Preferred Providers can be obtained by contacting Aetna Student Health at 877.850.6038.

Failure to utilize a network provider will result in a benefit reduction to 60% of covered charges.

In the case of a medical emergency as determined by the claims administrator, a participant who obtains health care from an out-of-network provider will be subject to the in-network limits and restrictions with respect to such care. When hospital or medical care is required because of a Sickness or Injury eligible for benefits under this Plan, the reasonable and customary expense actually incurred will be paid, up to the specified limits for each Sickness or Injury.

Pre-Certification Program

Your Plan requires pre-certification for certain services, such as inpatient stays, certain tests, procedures, outpatient surgery, therapies and equipment, and prescribed medications. Pre-certification simply means calling Aetna Student Health prior to treatment to get approval for coverage under your Plan for a medical procedure or service. For preferred care and designated care, the preferred care or designated care provider is responsible for obtaining pre-certification Since precertification is the preferred care or designated care provider's responsibility, there is no additional out-of-pocket cost to you as a result of a designated care provider's or a preferred care provider's failure to precertify services. For non-preferred care, you are responsible for obtaining pre-certification which can be initiated by you, a member of your family, a hospital staff member or the attending physician. The precertification process can be initiated by calling Aetna at the telephone number listed on your ID card.

If you do not secure pre-certification for the below listed inpatient and outpatient covered medical services and supplies obtained from a non-preferred provider, your medical expenses for these services and supplies will not be covered.

Pre-certification for the following inpatient and outpatient services or supplies is needed*:

  • All inpatient maternity and newborn care, after the initial 48 hours for a vaginal delivery or 96 hours for a cesarean section;
  • Ambulance (non-emergency transportation);
  • Autologous chondrocyte implantation, Carticel®
  • Bariatric surgery (bariatric surgery is not covered under the Policy unless specifically described in the Policy.);
  • BRCA genetic testing;
  • Cardiac rhythm implantable devices;
  • Cochlear device and/or implantation;
  • Dental implants and oral appliances;
  • Dorsal column (lumbar) neurostimulators:trial or implantation;
  • Drugs and Medical Injectables;
  • Electric or motorized wheelchairs and scooters;
  • Gender Reassignment (Sex Change) Surgery;
  • Home health care related services (ie. private duty nursing),
  • Hyperbaric oxygen therapy;
  • Infertility treatment (Comprehensive and ART infertility treatment is not covered under the plan unless specifically described in the Policy.)
  • Inpatient Confinements (surgical and non-surgical); hospital, skilled nursing facility, rehabilitation facility, residential treatment facility for mental disorders and substance abuse, hospice care;
  • Inpatient mental disorders treatment;
  • Inpatient substance abuse treatment;
  • Kidney dialysis;
  • Knee surgery;
  • Limb Prosthetics;
  • Out-of-network freestanding ambulatory surgical facility services when referred by a network provider;
  • Oncotype DX;
  • Orthognatic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint;
  • Osseointegrated implant;
  • Osteochondral allograft/knee;
  • Outpatient back surgery not performed in a physician's office;
  • Pediatric Congenital Heart Surgery;
  • Pre-implantation genetic testing;
  • Procedures that may be considered cosmetic.Cosmetic services and supplies are not covered under the plan unless specifically described in the Policy;
  • Proton beam radiotherapy;
  • Referral or use of out-of-network providers for non-emergency services, unless the covered person understands and consents to the use of an out-of-network provider under their out-of-network benefits when available in their plan;
  • Spinal Procedures;
  • Transplant Services;
  • Uvulopalatopharyngoplasty, including laser-assisted procedures; and
  • Ventricular assist devices.

*Your Plan may not include coverage for all of the services and supplies listed above. Please check your Master Policy for confirmation of which services and supplies are covered and which services and supplies are excluded under your Plan. If you cannot locate the benefit you are looking for in your Master Policy, contact Customer Service at the number listed on your ID card for further assistance.

Pre-certification DOES NOT guarantee the payment of benefits for your inpatient stays, certain tests, procedures, outpatient surgeries, therapies and equipment, and prescribed medications
Each claim is subject to medical policy review, in accordance with the exclusions and limitations contained in the Master Policy. The Master Policy also includes information regarding your eligibility criteria, notification guidelines, and benefit coverage.

Pre-certification of non-emergency admissions
Non-emergency admissions must be requested at least fifteen (15) days prior to the date they are scheduled to be admitted.

Pre-certification of emergency admissions
Emergency admissions must be requested within twenty-four (24) hours or as soon as reasonably possible after the admission.

Pre-certification of urgent admissions
Urgent admissions must be requested before you are scheduled to be admitted.

Pre-certification of outpatient non-emergency medical services
Outpatient non-emergency medical services must be requested within fifteen (15) days before the outpatient services, treatments, procedures, visits or supplies are provided or scheduled.

Pre-certification of prenatal care and delivery

Prenatal care medical services must be requested as soon as possible after the attending physician confirms pregnancy. Delivery medical services, which exceed the first 48 hours after delivery for a routine delivery and 96 hours for a cesarean delivery, must be requested within twenty-four (24) hours of the birth or as soon thereafter as possible.