Aetna Appeal Form PDF Details

When medical professionals or healthcare providers encounter issues with insurance coverage decisions made by Aetna, the Practitioner and Provider Complaint and Appeal Request form becomes a critical tool. This form allows for a structured process to challenge such decisions, offering a pathway to potentially overturn denials of payment or disputes concerning service coverage. The form requires detailed information, including the member's ID, Plan Type (whether medical or dental), and specific provider details, to ensure a thorough review process. It mandates the submission of supporting documents such as medical records, lab reports, and any relevant correspondence to accompany the appeal, which should be sent to the address provided on the Explanation of Benefits (EOB) or other Aetna communications. The appeal can address multiple service dates for the same member, further streamlining the process for providers handling ongoing cases. Additionally, if a healthcare provider is acting on behalf of a member with the member's explicit consent, or appealing a preauthorization denial before services have been rendered, there is an option to note this on the form, ensuring the context of the appeal is clear. Addressing each appeal with adequate evidence and detailed explanations is crucial, as indicated by the space provided for an in-depth explanation of the appeal request, with the option to attach additional pages if necessary. The designated mailing and fax information facilitates timely submission, though the emphasis on comprehensive preparation underscores the importance of accuracy and thoroughness in each appeal process. This form serves as a vital link between healthcare providers and Aetna, aiming to ensure fair and justified insurance coverage decisions.

QuestionAnswer
Form NameAetna Appeal Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesaetna provider appeal request form, aetna complaint and appeal request, aetna provider appeals form, aetna reconsideration form 2021

Form Preview Example

Practitioner and Provider

Complaint and Appeal Request

NOTE: Completion of this form is mandatory. To obtain a review submit this form as well as information that will support your appeal, which may include medical records, office notes, discharge summaries, lab records and/or member history (this is not an all-inclusive list) to the address listed on your Explanation of Benefits (EOB) or other correspondence received from Aetna.

Please provide the following information.

(This information may be found on the front of the member’s ID card.)

Today’s Date

Member’s ID Number

Plan Type

MEDICAL

DENTAL

Member’s Group Number (Optional)

Member’s First Name

Member’s Last Name

Member’s Birthdate (MM/DD/YYYY)

Provider Name

 

TIN/NPI

Provider Group (if applicable)

 

 

 

 

Contact Name and Title

 

 

 

 

 

 

 

Contact Address (Where appeal/complaint resolution should be sent)

 

 

 

 

 

 

Contact Phone

Contact Fax

Contact Email Address

 

 

 

 

 

To help Aetna review and respond to your request, please provide the following information. (This information may be found on correspondence from Aetna.)

You may use this form to appeal multiple dates of service for the same member.

Claim ID Number (s)

Reference Number/Authorization Number

Service Date(s)

Initial Denial Notification Date(s)

Reconsideration Denial Notification Date(s)

CPT/HCPC/Service Being Disputed

Explanation of Your Request (Please use additional pages if necessary.)

Note: If you are acting on the member’s behalf and have a signed authorization from the member or you are appealing a preauthorization denial and the services have yet to be rendered, use the member complaint and appeal form.

You may mail your request to:

Aetna-Provider Resolution Team

PO Box 14020

Lexington, KY 40512

Or use our National Fax Number: 859-455-8650

GR-69140 (3-17)

CRTP

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Part number 1 of submitting aetna practitioner and provider complaint and appeal request

2. The subsequent stage is usually to fill out the following fields: Initial Denial Notification Dates, Reconsideration Denial, CPTHCPCService Being Disputed, Explanation of Your Request Please, Note If you are acting on the, You may mail your request to, AetnaProvider Resolution Team, and PO Box Lexington KY .

How to prepare aetna practitioner and provider complaint and appeal request stage 2

Those who work with this form generally make errors while filling out AetnaProvider Resolution Team in this area. Be certain to go over whatever you type in here.

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