File name: Aetna Claim Form Pdf
Rating: 4.4/5 (Based on 7569 votes)
13774 downloads
========================
========================
Find the insurance documents you need, including claims, tax, reimbursement and other health care forms. Also learn how to find forms customized specifically for your Aetna benefits as well . form must be completed before your claim can be considered. Claim Form from Continental Life Insurance Company of Brentwood, Tennessee An Aetna Company Page 1 of 2 • Print clearly . If completing this form on behalf of a Medicare Part D member, a valid CMS Appointment of Representative form (or equivalent) is required visit for a copy of the form. Visit or call the member services number on your member ID card for a prescription drug claim form. How to fill out this form? 1. Complete each section. Print clearly in black ink only or type the information in the form online. 2. Sign and date the bottom of the completed form. FOR FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION REGARDING ELECTRONIC CLAIM SUBMISSIONS. Complete items one (1) through nineteen (19) in full. Complete items twenty (20) through twenty-four (24) only if other medical coverage exists. When to use this form? 1. Fill out this form if you’re asking for a medical, dental, vision, hearing, or vaccine reimbursement and you paid a doctor, healthcare professional, or service provider who did not bill us directly. 2. Don’t use this form for prescription drug claim reimbursements. Visit form must be completed before your claim can be considered. Claim Form from Continental Life Insurance Company of Brentwood, Tennessee An Aetna Company Page 1 of 2 • Print clearly and use blue or black ink. © Aetna Inc. Full name of policyholder First, M.I., Last Policy number Policyholder address CityZip State. FOR FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION REGARDING ELECTRONIC CLAIM SUBMISSIONS. THE EMPLOYEE 1. Complete items 1 through 19 in full. 2. Complete items 20 through 24 only if other medical coverage exists. 3. FOR FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION REGARDING ELECTRONIC CLAIM SUBMISSIONS. Complete items one (1) through twenty-one (21) in full. Complete items twenty-two (22) through twenty-six (26) only if other medical coverage exists.
