Aetna Form Medical Benefits Request PDF Details

The Aetna Medical Benefits Request form is the official claim document for Aetna members seeking reimbursement or direct payment for medical services. It covers both in-network and out-of-network situations and is 7 pages long. You will need information from both yourself and your treating provider before you begin.

When Do You Need This Form?

You need to complete this form in several common situations:

What Information You Need Before You Start

Gather the following before filling out the form. Having everything ready will prevent delays in processing your claim:

Understanding the Legal Warnings

The form includes legally required warnings about insurance fraud. These vary by state but carry serious consequences everywhere. Submitting false or misleading information on a medical claim is a criminal offense. Penalties can include fines and imprisonment. Read the state-specific language on your form carefully before you sign.

Your signature also authorizes Aetna to access medical records relevant to your claim. The form will not be processed without a valid signature and date.

Coordination of Benefits

If you carry more than one health insurance plan, complete the coordination of benefits section in full. You will need to list your primary insurance plan information. Aetna processes your claim as a secondary insurer after the primary plan has paid. Leaving this section blank is one of the most common reasons claims are delayed or returned.

How Long Does Processing Take?

Aetna typically processes a complete and accurate medical claim within 30 days of receipt. Complex claims, missing documentation, or high claim volumes can extend this timeline. Submitting a fully completed form the first time is the single most effective way to avoid delays.

If your claim is denied or you disagree with the payment, you can request a review using the Aetna Appeal Form. An appeal must typically be filed within a specific window after the denial notice, so act promptly.

Related Aetna Forms

Depending on your situation, you may need to submit additional Aetna forms alongside your medical benefits request. The most commonly paired documents include:

You can also explore our full library of health insurance claim forms to find other documents you may need.

QuestionAnswer
Form NameAetna Form Medical Benefits Request
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesaetna reimbursement forms, medical benefits request form aetna, aetna health insurance claim form, aetna reimbursement forms get

Form Preview Example

Medical Benefits – Claim Instructions

Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Attention Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Attention Kansas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.

Attention Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false

information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Attention Missouri Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, denial of insurance and civil damages, as determined by a court of law. Any person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a court of law. Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation. Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such person to criminal and civil penalties. Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law. Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years. Attention Texas Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

NOTE: INCOMPLETE CLAIM FORMS WILL BE RETURNED TO YOU FOR MISSING INFORMATION. THIS WILL DELAY THE PROCESSING OF THE CLAIM. FOR FASTER, EASIER SUBMISSION OF CLAIMS, THE PROVIDER MAY CONTACT THE AETNA CLAIM PROCESSING CENTER FOR INFORMATION REGARDING ELECTRONIC CLAIM SUBMISSIONS.

TO THE MEMBER

1.Complete items one (1) through twenty-one (21) in full.

2.Complete items twenty-two (22) through twenty-six (26) only if other medical coverage exists.

3.Be certain to sign the authorization to release information in block twenty-seven (27).

4.If you wish to have your benefits for this claim paid directly to your physician or supplier, sign block twenty-eight (28).

5.If you have submitted a request for benefits to another plan, including Medicare, attach a copy of the bills you submitted to the other plan and the explanation of benefits you received from the other plan.

6.Attach itemized bills or ask your health care provider to complete the applicable section on the reverse side. The bills must include:

- patient's name- condition being treated - type of service(s) rendered - date(s) of service(s)- relationship to member If this information is missing, write it on the bill and sign your name.

7.If prescription drugs are covered under your plan, submit receipts or a Prescription Drug Record form. This information can be copied from the prescription bottle or box. Receipt must contain:

 

- drug name

-

purchase date

-

prescription number

-

pharmacy name/address

-

dose per/day

 

- nature of illness or injury

-

quantity

-

charge

-

strength

-

physician's name

8.

Retain copies of your bills for your record.

 

 

 

 

 

 

9.

Send the completed benefits request and the bills to:

Aetna Life Insurance Company

 

 

 

 

 

 

 

 

PO Box 981106

 

 

 

 

 

 

 

 

El Paso, TX 79998

 

 

 

 

TO THE PHYSICIAN OR SUPPLIER

1.Complete items twenty-nine (29) through forty-five (45) in full.

2.If the member indicates that benefits should be paid directly to the physician or supplier, then these benefits will be sent directly to you with an information copy of the transactions to the member.

GC-7-42 (10-16)

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Medical Benefits Request

Mail to: Aetna Life Insurance Company

 

 

 

 

 

PO Box 981106

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

El Paso, TX 79998

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED BY MEMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

School Name

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Policy/Group Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Member’s Aetna ID Number

4.

Member’s Name

 

 

 

 

 

 

 

5.

Member’s Birthdate (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Member’s Address (include ZIP Code)

Address is new

 

 

 

 

 

 

 

7.

Member’s Daytime Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Patient's Name

 

 

 

9.

Patient's Aetna ID Number

 

 

10. Patient's Birthdate (MM/DD/YYYY)

11. Patient's Relationship to Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Spouse

Child

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Patient's Address (if different from member)

13. Patient's Gender

14. Full Time Student

15. Patient's Expected Graduation Date

16. Name of School and City

 

 

 

 

 

 

 

 

 

Male

Female

 

No

 

Yes

 

 

 

 

 

 

 

 

 

17.

Patient's Marital Status

18. Is patient employed?

 

 

 

 

19. Name and Address of Employer

 

 

 

 

 

 

 

 

Married

 

Single

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Is claim related to an accident?

 

 

 

 

 

 

 

 

 

 

21. Is claim related to employment?

 

 

 

No

Yes

If Yes, date

 

 

 

 

 

time

 

 

 

am

pm

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

22.

Are any family members expenses covered by another group health plan, group pre-

 

23. If Yes, list policy or contract holder, policy or contract number(s) and name/address of

 

payment plan (Blue Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any

 

insurance company or administrator:

 

 

 

 

 

 

 

 

 

federal, state or local government plan?

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

Member’s ID Number

25. Member’s Name

 

 

 

 

 

 

 

26. Member’s Birthdate (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27. To all providers of health care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies (“Aetna”), and any independent claim administrators and consulting health professionals

 

and utilization review organizations with whom Aetna has contracted, information concerning health care advice, treatment or supplies provided the patient (including that relating to

 

 

 

mental illness and/or AIDS/ARC/HIV). This information will be used to evaluate claims for benefits. Aetna may provide the employer named above with any benefit calculation used in

 

payment of this claim for the purpose of reviewing the experience and operation of the policy or contract. This authorization is valid for the term of the policy or contract under which a

 

claim has been submitted. I know that I have a right to receive a copy of this authorization upon request and agree that a photographic copy of this authorization is as valid as the original.

 

Patient's or Authorized Person's Signature

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

28. I authorize payment of medical benefits to the physician or supplier of service.

 

Patient's or Authorized Person's Signature

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED BY PHYSICIAN OR SUPPLIER

 

 

 

 

 

 

29.

Date of Illness (first symptom) or injury

 

30. Date first consulted you for this condition

31.

If patient has had similar illness or injury, give

32. If an emergency check here.

 

 

(accident) or pregnancy (LMP)

 

 

 

dates

 

emergency

 

33.

Name of referring physician (e.g., Public Health Agency)

34.

For services related to hospitalization give hospitalization dates

 

 

 

 

 

 

admitted

discharged

 

 

 

 

 

 

 

 

 

 

 

35.Name & address of facility where services rendered (if other than home or office)

36.Diagnosis or nature of illness or injury (please indicate primary and secondary)

37.Procedures, Medical Services, Supplies Furnished

Date of

 

Place of

Procedure Code

 

 

 

 

 

Type of

 

 

Days or

 

 

 

Service

 

Service*

Identify**

 

Description of Service

 

 

Service

Charges

 

Units

Diagnosis Code 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38. Physician's Name & Address (include ZIP Code)

 

39. Telephone Number

40. Enter the taxpayer identifying number to be used for

 

 

 

 

 

 

 

 

(

)

 

 

1099 reporting purposes. You are required under

 

 

 

 

 

 

 

 

 

 

 

 

authority of law to furnish your taxpayer identifying

 

 

 

 

 

 

 

 

 

 

 

 

number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

41. Patient Account Number

 

 

42. Total charge $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount paid $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Balance due $

 

 

 

 

 

 

 

 

 

 

 

43. Physician's or Supplier's Signature

 

 

 

44. National Provider Identifier

 

 

45. Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Place of Service Codes:

 

 

 

 

 

Type of Service Codes:

 

 

 

 

 

 

1

- (IH)

- Inpatient Hospital

 

8 - (SNF)

- Skilled Nursing Facility

1

- Medical Care

 

8 - Assistance at Surgery

2

- (OH)

- Outpatient Hospital

9 -

 

- Ambulance

2

- Surgery

 

9 - Other Medical Service

3

- (O)

- Office Visit

 

0 - (OL)

- Other Location

3

- Consultation

 

0 - Blood or Packed Red Cells

4

- (H)

- Patient Home

 

A - (IL)

- Independent Laboratory

4

- Diagnostic X-Ray

 

A - Used DME

 

 

 

5

-

- Day Care Facility (PSY)

B -

- Other Medical Surgical Facility

5

- Diagnostic Laboratory

M - Alternate Payment for Maintenance Dialysis

6

-

- Night Care Facility (PSY)

C - (RTC)

- Residential Treatment Center

6

- Radiation Therapy

 

Y - Second Opinion on Elective Surgery

7

- (NH)

- Nursing Home

 

D - (STF)

- Specialized Treatment Facility

7

- Anesthesia

 

Z - Third Opinion on Elective Surgery

** Please Use Current Procedural Terminology Codes for Surgery

Please Use ICD Code for Discharge Diagnosis

 

 

 

GC-7-42 (10-16)

 

 

 

 

 

 

 

 

 

 

 

 

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Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, contact:

Civil Rights Coordinator,

P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),

1-800-648-7817, TTY: 711,

Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with Civil Rights Coordinator.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

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GC-7-42 (10-16)

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GC-7-42 (10-16)

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How to Edit Aetna Form Medical Benefits Request Online for Free

How to Complete the Form Using the FormsPal Editor

The FormsPal PDF editor lets you fill out the Aetna Medical Benefits Request form directly in your browser. No downloads or installations are required. Follow the steps below to complete and save your form.

Step 1: Click the orange "Get Form" button at the top of this page. The editor will open with the form loaded and ready.

Step 2: Use the text tools to type into each field. You can add checkmarks, insert your signature, and adjust the position of any element as needed.

aetna form benefits form completion process described (part 1)

Step 3: Review your completed form carefully. Confirm that all required fields are filled in and that names, dates, and ID numbers are accurate.

Step 4: Click "Done" when you are satisfied. You can download the completed PDF or email it directly from the editor.

Member Section Fields

The first part of the form covers your personal information as the insured member. Fill in these fields accurately:

  • Your full legal name and date of birth
  • Your Aetna member ID and group number
  • Your mailing address for correspondence
  • Relationship to the subscriber if you are covered as a dependent
  • Whether payment should go directly to your provider or to you
  • Your signature authorizing Aetna to access relevant medical records
Writing segment 2 of aetna form benefits form

Physician and Provider Section Fields

The second part of the form must be completed by your treating physician or their billing office. Common fields include:

  • Physician name, license number, and contact details
  • Dates of service for each procedure or visit being claimed
  • Diagnosis codes (ICD codes) for the condition treated
  • Procedure codes (CPT codes) for each service rendered
  • Whether the condition was related to an accident, emergency, or pregnancy
  • Name of the referring physician if applicable

Common Errors to Avoid

Most claim delays and rejections result from preventable errors. Watch for these common mistakes:

  • Incorrect member ID or group number. Confirm these directly from your Aetna insurance card before entering them
  • Wrong dates of service. A single incorrect date can cause the entire claim to be returned
  • Missing procedure or diagnosis codes. Get these from your provider's billing office rather than guessing
  • Incomplete coordination of benefits section when you have dual coverage
  • Missing signature. An unsigned form will not be processed regardless of how accurately the rest is completed

Where to Submit Your Form

Submit your completed Aetna Medical Benefits Request form to the address printed on the back of your Aetna insurance card. The correct mailing address depends on your specific plan type. Keep a copy of the completed form and all supporting documents for your records.

If your claim is delayed beyond 30 days, contact Aetna member services using the number on your insurance card. You can also check claim status through the Aetna member portal.

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