Aetna Appeal Form PDF Details

Aetna is a health insurance company that offers its services throughout the United States. If you are not happy with your plan or feel that you have been treated unfairly, you may want to consider filing an appeal. In this blog post, we will go over the process of filing an appeal with Aetna and what to expect. Keep in mind that the process may vary depending on your state and the specific situation. If you would like more information, please consult Aetna's website or call their customer service line. We hope this information is helpful!

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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It is simple to fill out the document with this helpful tutorial! Here's what you should do:

1. When filling out the aetna practitioner and provider complaint and appeal form, ensure to complete all of the needed blanks within the relevant form section. This will help to speed up the work, enabling your information to be handled promptly and accurately.

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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