Aetna International Claim Form PDF Details

Aetna International Claim Form is a document that allows you to submit your claim for reimbursement by Aetna for medical expenses incurred outside of the United States. This blog post will explain what an international claim form is, how it works and why it should be filed. In order to file an international claim form with Aetna, there are several things that must be done before hand such as filing a written request from the patient's doctor or other health care provider which explains in detail why treatment was not available within the United States, submitting any supporting documentation and filling out all necessary information on the application itself.

These are some facts you might like to read before you start working with the aetna international claim form.

QuestionAnswer
Form NameAetna International Claim Form
Form Length2 pages
Fillable?Yes
Fillable fields19
Avg. time to fill out4 min 18 sec
Other namesaetna mileage reimbursement form, aetna medical claim reimbursement form, aetna ppo claim form, aetna reimbursement form for prescriptions

Form Preview Example

Aetna International Claim Form

Please submit this completed Claim form with itemized bills and receipts. A separate Claim Form is needed for each family member. Please tape small receipts on a full size sheet of paper. Failure to complete all sections of this form may result in claim processing delays.

Medical

Dental

Maternity

Vision

Wellness

Please refer to your policy documents to verify the cover available through your Plan.

Important Note: Please ensure Your Claim Form is completed in full and returned within 180 days of the Treatment date.

1. Member Information – Must be completed.

Policy Name

 

Policy Number

 

Member's Name

 

 

 

 

 

Member's Date of Birth

 

Member Aetna Identification Number

 

 

Street Address

 

 

 

 

 

City

 

State/Province

 

Country

 

Postal/ZIP Code

 

Member's Telephone Number

 

Mobile Number

 

 

Member's E-Mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Patient Information – Must be completed.

 

 

 

 

Patient's Full Name

 

 

Patient's Date of Birth

 

 

Gender

Male

Female

Relationship

Patient’s Aetna Identification Number

Self

Spouse

Child

Other

3. Other Health Insurance Coverage – Must be completed.

Do you hold any other insurance?

No

Yes

Other Carrier Name

Other Insurance Policy Number

 

 

 

Policy Holder Name

Please submit the relevant documents for the details if you get the reimbursement from other insurance for this claim submission.

4.Claim Information (Please include diagnosis or reason for treatment for each service received.)

For services related to an accidental injury, details of the accident must be provided.

For conditions that have required long term treatments, please provide details of when the symptoms and/or treatment began.

Claims for prescribed drugs or medication should include a prescription from your general practitioner (GP) or medical specialist.

Acupuncture, Podiatry, Chiropractic, Osteopath, Homeopath treatment and physiotherapy require a referral from your GP or medical specialist.

If you have insufficient space in any section, please provide full details on separate sheet.

 

 

Description of

 

 

 

 

 

Provider's (physician, clinic,

Service/ Name of

 

 

 

 

 

hospital, pharmacy, dentist)

Medication/ Device

 

 

 

 

 

Name and Address (If the

(If hospital, state

 

 

 

 

Dates of

provider’s name and address is

Inpatient, Day Case

Diagnosis

 

Currency

Total

Services

on receipts, write “see receipts”)

or Outpatient)

(Reason for visit)

Country of Claim

of Claim

Charge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the claim is for Maternity please indicate the expected due date of the pregnancy.

Please confirm if your pregnancy is a result of assisted conception/infertility treatment.

For dental claims, please indicate the related tooth and ensure itemized breakdown of services is included.

Were your injuries caused by an Accident?

No

Yes

 

 

If Yes, is it: Motor Vehicle Related?

No

Yes, provide Accident Date

 

Time

Work Related?

No

Yes, provide Accident Date

 

Time

Please provide accident details on a separate sheet.

AM AM

PM PM

Please Retain a Copy for Your Records

Policies issued in Hong Kong are issued by GAN Assurances IARD and administered by Aetna Global Benefits (Asia Pacific) Limited, an Aetna Company. Aetna Global Benefits (Asia Pacific) Limited registered address: Suite 401-403, DCH Commercial Centre, 25 Westlands Road, Quarry Bay, Hong Kong. Insurance Registration No. 02905813.

GR-68747-3 HK (9-12)

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Member’s Name (For faxing purpose):

5. Summary of Payment Details – Must be completed.

Recurring Reimbursement Election – Please check one of the following options if you want to:

Receive future payments using the details provided below

Use the payment information provided below for this claim only

Use the payment details that we already have on file for you

Payment Information

 

Please select your preferred reimbursement method:

Bank Transfer

Cheque

 

 

 

 

 

(If no selection is made, the default method is cheque issued in the member’s name.)

 

 

 

 

 

Please indicate your preferred payment currency (If none is indicated, the default currency is US Dollar.)

 

 

 

 

Payee Name

 

 

 

 

Specify if:

Member

Provider

Employer

 

 

Claim Settlement Address (if different to Section 1):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State/Province

Country

 

 

 

 

If you have selected Bank Transfer as your preferred payment method, the following information is required:

 

 

 

Bank Account Holder Name (as per Bank Statement)

 

 

 

 

 

 

 

 

 

 

 

 

Bank Account Number

 

 

 

Sort Code/Branch Code

 

 

 

 

 

 

IBAN Code*

 

 

 

Swift/BIC Code

 

 

 

 

 

 

IFSC/ABA/ US Routing Code

 

 

 

 

 

 

 

 

 

 

 

 

Bank Name

 

 

 

 

 

 

 

 

 

 

 

 

Bank Address (include Country)

Bank Telephone Number (include Country Code)

*The IBAN is mandatory for bank transfer claim payment transactions in certain countries, such as the United Arab Emirates (UAE). This must be supplied if you are using a bank account in one of these countries. Members should check with their bank to confirm any IBAN requirements.

The most efficient method of receiving your benefits reimbursement is via Bank Transfer. Please check with your bank for help with providing the appropriate instructions to Aetna International.

6.Declaration – Must be completed.

I declare that, to the best of my knowledge, all the information provided on this claim form is truthful and correct. I understand that Aetna will rely on the information provided as such. I agree and accept that this declaration gives Aetna, and its appointed representatives, the right to request past, present, and future medical information in relation to this claim, or any other claim related to the member/covered individual, from any third party, including providers and medical practitioners. I declare and agree

that personal information may be collected, held, disclosed, or transferred (worldwide) to any organization within the Aetna group, its suppliers, providers and any affiliates.

Patient's Signature

 

Date

(If patient is under 18 years of age, Parent or Guardian must sign.)

 

Important Note: Please ensure Your Claim Form is completed in full and returned within six months (180 days) of the Treatment date. Failure to complete your form in full will result in the form being returned to you and will delay the processing of your claim. Please note Aetna International is not responsible for any costs associated with the completion of this form or for any further information/ document requested by Us to assess Your claim. The issuing of this Claim Form is in no way an admission of liability.

Please refer to your Member Handbook under General Claims Information for In-Patient, Day-Patient, Out-Patient Treatment and Pre-authorizations for all MRI and CT scans.

7. Additional Information

How to submit a Claim

Aetna International provides alternative methods of submitting a claim form to make it easier for our members, below are the listed options:

Postal Submission

Online Claim Submission for our members via our

Aetna Global Benefits (Asia Pacific) Limited

secure portal

Suite 401-403

www.AetnaInternational.com

DCH Commercial Centre

Submit your claim via Fax attaching receipts and

25 Westlands Road

referrals from your Medical Practitioner

Quarry Bay

+852-2866-2555

Hong Kong

Email Submission with copies of your receipts and

 

referrals from your Medical Practitioner

 

AsiaPacServices@aetna.com

 

For claim related queries please contact our 24 hour

 

Member Services helpline

 

+852-3071-5022

Please Retain a Copy for Your Records

Policies issued in Hong Kong are issued by GAN Assurances IARD and administered by Aetna Global Benefits (Asia Pacific) Limited, an Aetna Company. Aetna Global Benefits (Asia Pacific) Limited registered address: Suite 401-403, DCH Commercial Centre, 25 Westlands Road, Quarry Bay, Hong Kong. Insurance Registration No. 02905813.

GR-68747-3 HK (9-12)

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How to Edit Aetna International Claim Form Online for Free

The idea driving our PDF editor was to help it become as easy to use as possible. You'll find the overall procedure of managing aetna dental claim form pdf hassle-free should you follow the following steps.

Step 1: Click the "Get Form Here" button.

Step 2: At this point, you can start editing the aetna dental claim form pdf. The multifunctional toolbar is at your disposal - add, eliminate, adjust, highlight, and undertake other sorts of commands with the content material in the document.

Enter the data required by the system to prepare the form.

aetna claim forms for medical fields to complete

Make sure you provide your details in the box Dates of Services, provider’s name and address is on, Inpatient, Diagnosis, or Outpatient), (Reason for visit) Country of Claim, Currency of Claim, Total, Charge, If the claim is for Maternity, Please confirm if your pregnancy, For dental claims, Were your injuries caused by an, If Yes, and Work Related.

Finishing aetna claim forms for medical part 2

In the Member’s Name (For faxing purpose):, Receive future payments using the, Cheque (If no selection is made, Bank Transfer, Please indicate your preferred, Specify if:, Member, Provider, If you have selected Bank Transfer, Employer, Street, City Bank Account Holder Name (as, IBAN Code* IFSC/ABA/ US Routing, State/Province, and Country area, point out the important information.

stage 3 to finishing aetna claim forms for medical

Within the section I declare that, Patient's Signature, (If patient is under 18 years of, Date, Important Note: Please ensure Your, Please refer to your Member, How to submit a Claim Aetna, (cid:129), Postal Submission, (cid:129), Online Claim Submission for our, Aetna Global Benefits (Asia, secure portal, (cid:129), and Submit your claim via Fax, identify the rights and obligations of the parties.

Filling in aetna claim forms for medical stage 4

Step 3: Once you've hit the Done button, your form is going to be accessible for upload to each electronic device or email address you identify.

Step 4: Ensure that you keep away from potential complications by having a minimum of 2 copies of your document.

Watch Aetna International Claim Form Video Instruction

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