How to Complete the Aetna Better Health of Virginia Prior Authorization Form

To request prior authorization from Aetna Better Health of Virginia, providers complete either the Physical Health Standard Prior Authorization Request Form or the Universal Pharmacy Prior Authorization Request Form, attach supporting clinical records, and submit through the Availity provider portal or the fax number that matches the service type. Both forms are available on Aetna’s Virginia Medicaid website and on Availity. Incomplete forms get returned, and Aetna’s decision clock does not start until a complete request arrives.

Which Form to Use

Most non-pharmacy services use the Physical Health Standard Prior Authorization Request Form. Pharmacy requests use the Universal Pharmacy Prior Authorization Request Form. Some service areas have their own dedicated forms and fax lines, including mental health, addiction and recovery treatment services (ARTS), and medical injectables. Some drug classes also have specific forms beyond the standard pharmacy PA form.¹

Before completing anything, confirm the service actually requires PA. Emergency care never does. Planned hospital admissions always do, and scheduled ambulatory surgery requires at least 72 hours’ advance notice. Services from out-of-network providers also require authorization. To check a specific procedure code, use ProPAT, Aetna’s online search tool, or the current list on the Availity portal.²

Completing the Physical Health Form

Every field marked “required” must be filled in. Returned forms restart the entire timeline.

Member Information

The top of the form collects the member’s name, date of birth, sex, and Medicaid identification number. The member ID must match what Aetna has on file exactly.³

Provider Information

The provider section asks for two sets of details: the referring or requesting provider, and the service provider or facility that will actually perform the procedure. For each, enter the name, address, phone and fax numbers, specialty, and National Provider Identifier (NPI). Include a direct contact person at the office. Aetna uses that contact to request clarifications, and a blank field slows the review.¹

Diagnosis and Procedure Codes

Enter ICD-10 diagnosis codes with their descriptions and the CPT or HCPCS codes identifying the exact service or equipment requested. Both are required. Add the dates of service, the number of visits requested, and the place of service (outpatient, inpatient, or office).³

Completing the Pharmacy Form

The Universal Pharmacy Prior Authorization Request Form collects the member’s name, date of birth, gender, height, weight, and Medicaid ID, along with the prescribing provider’s name, specialty, NPI, and DEA number.⁴

The medication section asks for the drug name, strength, dosage form, directions for use, quantity, number of refills, and duration of therapy. For a brand-name-only request, check the appropriate box and include a copy of the MedWatch form. The clinical section asks whether this is a new request or a continuation, what medications the member has previously tried and failed for this diagnosis (with dates and reasons for stopping), and any supporting lab results.

The form itself states that Aetna returns incomplete submissions and submissions without chart notes. Mark a request urgent only if waiting for a standard decision could seriously harm the member’s health.⁴

Clinical Documentation That Supports Approval

The clinical rationale decides most reviews. Attach clinical notes, laboratory results, imaging reports, and any other records that support the diagnosis and the proposed treatment plan. The provider manual directs that all clinical information be submitted with the request up front, not after it is asked for.¹

Documentation should show that less intensive alternatives were either tried without adequate results or would be clinically inappropriate. Reviewers compare submissions against Aetna’s Clinical Policy Bulletins, which are published on the Aetna website. Identifying the bulletin that applies to the requested service lets you tailor your documentation to the specific criteria the reviewer will use.⁵

Where to Submit the Completed Form

Aetna accepts PA requests through the Availity provider portal, by fax, and by phone. Availity runs validation checks before you submit and lets you track status afterward, and it is available around the clock.¹

For fax submissions, use the number that matches the service. Using the wrong fax number is one of the easiest ways to delay a request:

General prior authorization: 1-833-280-5224
Pharmacy: 1-855-799-2553
Inpatient concurrent review: 1-877-817-3707
Behavioral health and ARTS: 1-833-757-1583
Medical injectables: 1-844-956-1191
LTSS authorizations: 1-844-459-6680
Legacy M4: 1-866-669-2454
Legacy Plus: 1-855-661-1828

Include a cover sheet with the practice’s correct phone and fax numbers to protect patient health information and give Aetna a way to reach you. Keep the fax transmission report as proof of delivery. To submit or follow up by phone, call the Prior Authorization department at 1-800-279-1878.¹

Pharmacy requests can also go through CoverMyMeds or SureScripts at no charge, which bypasses both the portal and the fax machine.¹

Paper submissions mail to Aetna Better Health of Virginia, ATTN: Provider Relations, PO Box 818044, Cleveland, OH 44181-8044. Mail is the slowest option and adds transit time before the review clock starts.⁶

How Long Aetna Has to Decide

Starting January 1, 2026, a federal rule shortens the standard PA decision window from fourteen calendar days to seven calendar days for all Virginia Medicaid managed care organizations, including Aetna Better Health. The clock begins when Aetna receives a complete request, not when you fax an incomplete one.⁷

Standard pharmacy reviews have a 24-hour turnaround.⁴ If waiting for a standard decision could seriously jeopardize the member’s life, physical or mental health, or ability to function, the provider can request an expedited review, and Aetna must decide within 72 hours of receiving the request.⁸

Aetna communicates decisions through the Availity portal and sends written notifications to both the member and the provider. A denial or partial approval will explain the clinical reasoning and the member’s appeal rights.

If the Request Is Denied

When Aetna denies a PA request or reduces, stops, or delays a covered service, the member has 60 calendar days from the date on the written notice to file an internal appeal with Aetna. Standard internal appeals get a decision within 30 calendar days, which Aetna can extend by up to 14 days with written notice if more information is needed and the delay is in the member’s interest.⁹

If waiting 30 days could harm the member’s health, the member or provider can request an expedited appeal. Aetna must decide expedited appeals within 72 hours for Cardinal Care members or 48 hours for FAMIS members. Qualifying situations include urgent or emergency care needs, a current hospital stay, and availability of care. If Aetna finds the situation does not meet the expedited threshold, it will notify the member by phone and letter and process the appeal under the standard 30-day timeline.⁹ Appeals faxed to Aetna go to 1-866-669-2459.

If Aetna’s internal appeal upholds the denial, the member has 120 days from the date of that final decision to request a state fair hearing through the Virginia Department of Medical Assistance Services, filed in the DMAS Appeals Information Management System (AIMS) portal. The internal appeal must come first, because DMAS reviews the MCO’s final decision rather than the original PA denial.¹⁰¹¹

1
Aetna Better Health of Virginia. Provider Manual
2
Aetna Better Health of Virginia. Prior Authorization for Providers
3
Aetna Better Health of Virginia. Physical Health Standard Prior Authorization Request Form
4
Aetna Better Health of Virginia. Pharmacy Prior Authorization Request Form
5
Aetna. Clinical Policy Bulletins
6
Aetna Better Health of Virginia. Contact Us for Providers
7
Virginia Medicaid. Interoperability and Prior Authorization Final Rule Implementation Update
8
Virginia Medicaid. Interoperability and Prior Authorization Final Rule Implementation Update
9
Aetna Better Health of Virginia. File a Complaint/Grievance or Appeal
10
Virginia Code Commission. Virginia Administrative Code 12VAC30-120-650 – Appeal Timeframes
11
Virginia Medicaid. DMAS Appeals