Fillable Dental Benefits Claim Instructions (Aetna Health Insurance)

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Dental Benefits Claim Instructions (Aetna Health Insurance)

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Dental 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 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. 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.
Signature: Date (MM/DD/YYYY)
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 EMPLOYEE – USE BLACK INK ONLY
1. Complete blocks 1–22 in full.
2. Complete blocks 23–27 only if other dental coverage exists.
3. Be certain to sign the authorization to release information in block 28.
4. If you wish to have your benefits for this claim paid directly to your dentist, sign block 29.
If total charges for the planned course of treatment are expected to exceed the minimum Predetermination dollar amount stated in your dental plan booklet, it is suggested
you file for Predetermination of Benefits. Aetna Dental will notify your dentist of the benefits payable.
NOTE: YOUR DENTAL COVERAGE IS SUBJECT TO SPECIFIC LIMITATIONS AND EXCLUSIONS. PLEASE REFER TO YOUR DENTAL BOOKLET FOR
DESCRIPTION OF COVERED EXPENSES, DEDUCTIBLE AND COPAYMENT INFORMATION, AND LIMITATIONS AND EXCLUSIONS.
TO THE DENTIST – USE BLACK INK ONLY
1. COMPLETED SERVICES Check the box noted "STATEMENT OF SERVICES RENDERED" and complete blocks 30-48. When entering the treatment plan on the
form, please indicate a separate fee for each individual service rendered.
2. PREDETERMINATION OF BENEFITS If total charges for this claim are to exceed the minimum Predetermination dollar amount indicated in the employee's Dental Plan
Booklet (and treatment is not emergency in nature), Predetermination of Benefits is suggested. Check the box marked "PRE-TREATMENT ESTIMATE", and complete
blocks 30-48.
NOTE: PREDETERMINATION OF BENEFITS IS ONLY INTENDED TO AVOID MISUNDERSTANDINGS BETWEEN THE EMPLOYEE, DENTIST AND INSURANCE
COMPANY CONCERNING BENEFITS PAYABLE. YOU AND YOUR PATIENT ARE, OF COURSE, FREE TO PURSUE ANY TREATMENT PLAN YOU THINK BEST.
3. If the employee indicates that benefits should be paid directly to the dentist, these benefits will be sent directly to you with a copy of the transaction to the employee.
X-rays taken for metal restorations and crowns should be submitted with treatment plan. They may also be requested for other services. X-rays will be reviewed
by practicing Dentists and returned promptly.
TO THE EMPLOYEE & DENTIST
Send the completed benefits request and the bills to: Aetna Dental
PO Box 14094
Lexington, KY 40512-4094
GC-8-13 (10-19) N 1 R-POD
( )
Dental Benefits Request
Mail to: Aetna Dental
PO Box 14094
Lexington, KY 40512-4094
TO BE COMPLETED BY EMPLOYEE – USE BLACK INK ONL
Y
1. Employer's Name 2. Policy/Group Number
3. Employee's Aetna ID Number 4. Employee's Name 5. Employee's Birthdate (MM/DD/YYYY)
6. Active Retired
Date of Retirement
7. Employee's Address (include ZIP Code)
Address is new 8. Employee's Daytime Telephone Number
(
9. Patient's Name 10. Patient's Aetna ID Number 11. Patient's Birthdate (MM/DD/YYYY) 12. Patient's Relationship to Employee
Self Spouse Child Other
13. Patient's Address (if different from employee) 14. Patient's Gender
Male Female
15. Full Time Student
No Yes
16. Patient's Expected Graduation Date 17. Name of School and City
18. Patient's Marital Status
Married Single
19. Is patient employed?
No Yes
20.
Name and Address of Employer
21. Is claim related to an accident?
No Yes If Yes,
date time am pm
22. Is claim related to employment?
No Yes
23. Are any family members’ expenses covered by another group health plan, group pre-payment
plan (Blue Cross- Blue Shield, etc.), no fault auto insurance, Medicare or any federal, state or
local government plan? No Yes
24. If Y
es, list policy or contract holder, policy or contract number(s) and name/address
of insurance company or administrator:
25. Member’s ID Numbe
r 26. Member’s Name 27. Member’s Birthdate (MM/DD/YYYY)
28. To all providers of dental care:
You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies (“Aetna”), and any independent claim administrators and consulting dental professionals
and utilization review organizations with whom Aetna has contracted, information concerning dental care, advice, treatment or supplies provided the patient.
This information will be used
to evaluate claims for dental benefits.
Ae
tna 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
29. I authorize payment of dental benefits to the dentist or supplier of service.
Patient's or Authorized Person's Signature Date
TO BE COMPLETED BY DENTIST – USE BLACK INK ONL
Y
30. This is a request for:
Pre-Treatment Estimate Predetermination/Preauthorization Number Statement of Services Rendered
31. Dentist's Name & Address (include ZIP Code) 32. National Provider Identifier 33. Dentist License No. 34. Telephone Number
35. 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.
36. First Visit Date Current Series 37. Place of
Treatment
Office Hosp.
ECF Other
38. Radiographs or models enclosed?
No Yes
How many?
Is treatment
result of:
No Yes
If Yes, enter brief description and dates.
39. occupational illness or injury?
40. auto accident?
41. other accident?
42. Are any services covered by another plan?
43. If prosthesis, is this initial placement?
If No, date of prior placement and reason for replacement.
44. Is treatment for orthodontics?
Date appliance placed: Initial Appliance Fee:
No. of months of treatment: Monthly Fee:
Mos. of treatment remaining:
Total Case Fee:
45. To expedite claim handling, identify
all missing teeth with "X"
46. Examination and treatment plan. List in order from tooth no. 1 through tooth no. 32. Use charting system shown.
Tooth #
or Letter
If Previously
Extracted,
Give Date Surface
Description of Service (x-rays, prophylaxis,
materials used, etc.)
Date Service
Performed
MM DD
YYYY
Procedure
Number Fee
47. I hereby certify that the procedures as indicated by date have been completed and that the fees submitt
ed are the
actual fees I have charged this patient and intend to accept for those procedures.
Dentist's Signature Date
48. National Provider Identification
Total charge $
Amount paid $
Balance due
$
GC-8-13 (10-19) N 2
)
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, call the number on your ID card.
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 the Civil Rights Coordinator by
contacting:
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.
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).
GC-8-13 (10-19) N 3
TTY: 711
To access language services at no cost to you, call the number on your ID card.
Para acceder a los servicios de idiomas sin costo, llame al número que figura en su tarjeta de identificación.
(Spanish)
如欲使用免費語言服務，請致電您 ID 卡上的電話號碼 (Chinese)
Afin d'accéder aux services langagiers sans frais, veuillez composer le numéro inscrit sur votre carte d'identité.
(French)
Para ma-access ang mga serbisyo sa wika nang wala kayong babayaran, tawagan ang numero sa inyong ID card.
(Tagalog)
Um auf für Sie kostenlose Sprachdienstleistungen zuzugreifen, rufen Sie die Nummer auf Ihrer ID-
Karte an. (German)
Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit. (Albanian)
የቋንቋ
አገልግሎቶችን
ያለክፍያ
ለማግኘት፣
በመታወቂያዎት
ላይ
ያለውን
ቁጥር
ይደውሉ
(Amharic)
( Arabic) .ﺔﻴﺼﺨﺸﻟﺍ ﻚﺘﻗﺎﻄﺑ ﻰﻠﻋ ﺩﻮﺟﻮﻤﻟﺍ ﻢﻗﺮﻟﺍ ﻰﻠﻋ ﻝﺎﺼﺗﻻﺍ ءﺎﺟﺮﻟﺍ ،ﺔﻔﻠﻜﺗ ﻱﺃ ﻥﻭﺩ ﺔﻳﻮﻐﻠﻟﺍ ﺕﺎﻣﺪﺨﻟﺍ ﻰﻠﻋ ﻝﻮﺼﺤﻠﻟ
Անվճար լեզվական ծառայություններից օգտվելու համար զանգահարեք ձեր ինքնության (ID)
քարտի վրա նշված հեռախոսահամարով: (Armenian)
Kugira uronke serivisi z’indimi atakiguzi, Hamagara inumero iri kuri karangamuntu kawe. (Bantu)
Ngadto maakses ang mga serbisyo sa pinulongan alang libre, tawagan sa numero sa nimong ID card. (Bisayan-
Visayan)
Per accedir a serveis lingüístics sense cap cost per vostè, telefoni
al número indicat a la seva targeta
d’identificació. (Catalan)
Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion.
(Chamorro)
Anumpa tohsholi I toksvli ya peh pilla ho ish I paya hinla kvt chi holisso iskitini holhtena takanli ma I paya.
(Choctaw)
Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa duugda waraaqaa eenyummaa (ID) kee irraa jiruun
bilbili. (Cushite-Oromo)
Voor gratis toegang tot taaldiensten, bel het nummer op uw ID-kaart. (Dutch)
Pou jwenn sèvis lang gratis, rele nimewo telefòn ki sou kat idantite
ou a. (French Creole-Haitian)
Για να επικοινωνήσετε χωρίς χρέωση με το κέντρο υποστήριξης πελατών στη γλώσσα σας, τηλεφωνήστε στον
αριθμό που αναγράφεται στην κάρτα σας προνομίων μέλους. (Greek)
No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia
kōkua nei. (Hawaiian)
GC-8-13 (10-19) N 4
Xav tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID. (Hmong)
Iji nwetaòhèrè na ọrụ gasị asụsụ n'efu, kpọọ nọmba no na kaadị ID gị. (Ibo)
Tapno maaksesyo dagiti serbisio maipapan iti
pagsasao nga awan ti
bayadanyo, tawagan ti numero idiay ID
cardyo. (Ilocano)
Untuk mengakses layanan bahasa tanpa dikenakan biaya, hubungi nomor telepon di kartu identitas Anda.
(Indonesian)
Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero sulla tessera identificativa. (Italian)
言語サービスを無料でご利用いただくには、 IDカードに記載の番号にお電話ください。 (Japanese)
무료 언어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해 주십시오 . (Korean)
M
dyi wuɖu-dù kà kò ɖò
ɓě dyi mɔ
uń nì
pídyi
ní, nìí, ɖá nɔɓà nìà nì ID káàɔ
̃
kɔɛ.
(Kru-Bassa)
Nan etal nan
jikin jiban ko ikijen kajin ilo an ejelok onen nan kwe, kirlok nomba
eo ilo ID kaat
eo am.
(Marshallese)
Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID. (Micronesian-
Pohnpeian)
Të kɔɔr yïn wɛ
̈
ɛ
̈
r de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke cɔl kɔc ye kɔc kuɔny në nɔmba de abac tɔ
̈
në ID kard
du kɔu. (Nilotic-Dinka)
For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt. (Norwegian)
Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
(Pennsylvania Dutch)
Aby uzyskać dostęp do bezpłatnych usług językowych proszę zadzwonić
numer
telefonu na
Twojej Karcie
Identykującej
(Polish)
Para acessar os serviços de idiomas sem custo para você, ligue para o número que consta na sua identidade.
(Portuguese)
Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul dvs. de identificare. (Romanian)
Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на
вашей карточке участника плана. (Russian)
GC-8-13 (10-19) N 5
Mo le mauaina o auaunaga tau gagana e aunoa ma se totogi, vala’au le numera I luga o lau pepa ID. (Samoan)
Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici. (Serbo-Croatian)
Heeba a nasta jangirde djey wolde, apelou lamba djey do windi ha dereji Maada. (Sudanic-Fulfulde)
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho. (Swahili)
Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē
he
ngaahi lea kotoa, telefoni ki he fika ‘oku hā atu
‘i ho’o ID kaati. (Tongan)
Ren omw kopwe angei aninisin eman chon awewei (ese kamo), kopwe kori ewe nampa mei mak won noum ena
katen ID (Trukese)
Sizin için ücretsiz dil hizmetlerine erişebilmek için, kartınızdaki numarayı arayın. (Turkish)
Щоб отримати безкоштовний доступ до мовних послуг, задзвоніть за номером, вказаним на Вашій
ідентифікайній картці. (Ukrainian)
Nếu quý vị muốn sử dụng miễn phí các dịch vụ ngôn ngữ, hãy gọi tới số điện thoại ghi trên thẻ ID (Nhận dạng)
của quý vị. (Vietnamese)
Lati wọnú awọn isẹ èdè l’ọfẹ fun ọ, pe nọmba ori káádi idánimọ rẹ. (Yoruba)
GC-8-13 (10-19) N 6
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Dental Benefits Claim Instructions (Aetna Health Insurance)

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Completed 14 March 2021

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