Aetna Validation Form PDF Details

Aetna is one of the largest healthcare providers in the United States. The company provides a wide range of health insurance plans, as well as other health-related services. Recently, Aetna announced a new validation form that must be completed by all patients prior to receiving services. This form is designed to ensure that patients receive the correct care and treatment. In this blog post, we will discuss the details of the Aetna validation form and provide tips for completing it accurately.

Below, you'll discover a number of specifics about aetna validation form PDF. It is definitely worth taking the time to learn this just before you start submitting your document.

QuestionAnswer
Form NameAetna Validation Form
Form Length1 pages
Fillable?Yes
Fillable fields50
Avg. time to fill out10 min 19 sec
Other namesQPOS, confirmation form, HMO, aetnavalidation com

Form Preview Example

Contractual Validation Form - Atlanta

HMO/QPOS (Two-Nine Eligible Lives)

(This form must accompany all new case submissions. All information must be submitted 30 days prior to the effective date to ensure ID cards are received prior to effective date.)

Aetna U.S. Healthcare - Small Business Center

841 PRUDENTIAL DRIVE, 6TH FLOOR WEST, F602 JACKSONVILLE, FL 32207

PHONE: (800) 223-2125 FAX: (800) 814-5677

New Business Case Information:

Case Name:

 

Date Submitted:

 

/

/

Proposed Effective Date:

 

 

 

 

 

Producer Name:

Phone Number:

(

)

 

 

 

 

 

 

 

Fax Number:

(

)

 

Producer Assistant Name:

 

 

Phone Number:

(

)

 

General Agent Name:

Phone Number:

(

)

 

 

 

 

 

 

 

Fax Number:

(

)

 

If any of the information listed below is excluded or incomplete when the case is

submitted, all materials will be returned to the producer for completion.

Required documentation for new business case installation:

Employer master application

Employee individual application

Employer Verification Form Note: must be signed by employer.

Original copy of completed Individual Health Statement for each employee.

If group coverage currently exists, copy of recent prior carrier bill. Individuals on the bill should match those listed on the wage and tax statement

Copy of most recent calendar year wage and tax statement containing the names, salaries, etc. of all employees of the employer group. Employees who have terminated and work part time must be noted Copy of rate quote(s) including:

Complete proposal including rate and plan design

Employer signature on signable rate page and supporting rate documentation Rates must match the enrollment reported and effective date. If discrepancy exists please include documentation to support the discrepancy

COPY of binder check and completed Binder Submission Form. Send originals to address on form.

Broker of Record letter and commission forms

Additional Information:

To whom will the Aetna US Healthcare contract be issued?

 

 

oSole Proprietorship oPartnership

oCorporation oAssociation oProfessional Employer Organization

oOther _______________________

 

 

 

Does group coverage currently exist?

oYes oNo

 

 

If Yes, Indicate Carrier __________________________ Effective Date

/

/

At any time has the group been covered under an Aetna US Healthcare plan or affiliate?

oYes

oNo

If Yes, provide coverage dates: From ____________to__________________

 

 

Total eligible lives _________

 

 

 

How many employees are enrolled in the current employer sponsored medical plan; or if no prior coverage exists, how many employees are likely to enroll in this plan? ________

How many eligible employees are not expected to enroll because they have spousal or individual coverage? _____

Do all eligible employees work 25 hours or more? oYes oNo

What percentage of the cost of the plan will the employer contribute? Employee only _____% Dependent ____%

Broker Signature:

 

Date:

ATLANTA HMO/QPOS 2-9 CVF (05/04/2001

How to Edit Aetna Validation Form Online for Free

We have applied the hard work of the best software engineers to develop the PDF editor you are going to take advantage of. The app will enable you to prepare the 6th form easily and don’t waste valuable time. What you need to do is comply with the next quick guidelines.

Step 1: Search for the button "Get Form Here" on the following webpage and next, click it.

Step 2: Now, you can begin modifying your 6th. The multifunctional toolbar is readily available - insert, erase, adjust, highlight, and do other sorts of commands with the text in the file.

To prepare the document, type in the content the application will ask you to for each of the appropriate sections:

confirmation form spaces to complete

Jot down the information in the IfYesIndicateCarrierEffectiveDate, and IfYesprovidecoveragedatesFromto area.

step 2 to filling out confirmation form

The program will require for more information in order to quickly fill in the box BrokerSignature, Date, and AtlantaHMOQPOSCVF.

confirmation form BrokerSignature, Date, and AtlantaHMOQPOSCVF fields to complete

Step 3: Choose the Done button to save your form. At this point it is at your disposal for upload to your device.

Step 4: In order to prevent possible upcoming issues, make sure to have at least a pair of copies of each file.

Watch Aetna Validation Form Video Instruction

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