Aetna 2025–2026 Policy Changes: Key Impacts on Eligibility Verification, Billing, and Collections Teams
Aetna has released a series of policy updates that will significantly impact providers across Medicare Advantage and commercial plans, particularly in the areas of pre-approvals, coding, and billing compliance. These changes, effective between late 2025 and early 2026, are expected to reshape workflows for eligibility verification, billing, and collections.
- Pre-Approval for Inpatient Rehab, Skilled Nursing, and Home Health (Medicare Advantage NJ/NY/PA/WV)
Effective January 1, 2026, Aetna will require prior authorization through EviCore for inpatient rehab, skilled nursing, and certain home health services.
Impact: Eligibility verification teams must ensure pre-approvals are secured before billing. Claims submitted without authorization face a high risk of denials, leading to rework and appeals.
- Site of Care Rules for Specialty Drug Administration (Commercial)
Aetna has reinforced its “site of care” requirements for specific infusion and injection drugs such as Avastin and Krystexxa.
Impact: Reimbursement will depend on service location. Providers must confirm approved sites during eligibility checks and prior to scheduling or billing.
- National Precertification List Updates
New specialty drugs and certain procedures have been added to Aetna’s National Precertification List, with implementation dates spanning 2025–2026.
Impact: Eligibility verification must confirm precertification status for relevant CPT/HCPCS codes. Claims lacking valid precertification will be denied.
- Coding Changes for Compression Stockings (Commercial)
Starting January 1, 2026, new HCPCS codes will apply to non-covered compression stocking supplies.
Impact: These items are not covered by Aetna and should be billed directly to patients where applicable
- Clarified CPT Codes for Lesion Excisions
From November 1, 2025, Aetna will apply clarified CPT guidance for coding skin and subcutaneous lesion excisions.
Impact: Coders must follow the updated rules to avoid billing denials.
- CPAP Adherence Documentation Requirements
Beginning December 1, 2025, Aetna will require proof of patient adherence for CPAP therapy. This must be documented using specific G-codes.
Impact: Claims without adherence documentation will be denied. Billing and eligibility verification teams must confirm compliance before submission.
Industry Outlook
These changes underscore Aetna’s ongoing shift toward tighter utilization management and documentation-driven reimbursement. Providers are urged to update internal workflows, retrain coding teams, and strengthen eligibility verification processes well ahead of the effective dates to minimize claim denials and payment delays.
