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Proprietary
When to use this form?
1. Fill out this form if you’re asking for a medical, dental, vision, hearing, or vaccine reimbursement
and you paid a doctor, healthcare professional, or service provider who did not bill us directly.
2. Don’t use this form for prescription drug claim reimbursements. Visit www.aetnamedicare.com
or call the member services number on your Aetna member ID card for a prescription drug claim
form.
How to fill out this form?
1. Complete each section. Print clearly in black ink only, or type the information in the form online.
2. Sign and date the bottom of the completed form. Appointed representatives must have an
Appointment of Representative form on file with the health plan, or you can submit one with this
form. You can find an Appointment of Representative form on www.aetnamedicare.com.
Where to send the completed form?
1. Make copies of all of your receipts and itemized bills from your provider. Be sure to include your
Aetna member ID number on each receipt and bill. All materials submitted will be retained by us
and cannot be returned to you.
2. Mail this completed form and your original receipts and itemized bills to the medical claims
address on your Aetna Medicare member ID card.
3. Or you can fax this completed form, your original receipts and itemized bills to 1-866-474-4040.
Things to remember
1. Please submit this form within 365 days from the date you received the service or item.
2. If your request is incomplete, we’ll return it to you and this will delay processing.
3. If the provider you paid is contracted with us, we will always pay the provider directly at the
contracted rate. You should ask the provider to pay you back.
4. If we approve your request, it can take up to 45 days to send payment once we have all the
required information.
Questions?
We’re here to help. Just give us a call at the number on your Aetna Medicare member ID card.
Acknowledgement
You understand it is a crime to fill out this form with information you know is false. You understand
that submission of a claim is not a guarantee of payment, or payment in the full amount. You
understand if the services are deemed covered services then the health plan will reimburse you up to
the benefit amount minus any applicable deductibles, coinsurance, or copayments. You understand
we may need to disclose the information on the form to other persons and entities to process the
claim.
How to complete this Medical Claim Reimbursement Form
Medicare Medical Claim Reimbursement Instructions
Proprietary
Member information (print clearly)
Aetna member ID number: Date of birth (MM/DD/YYYY): Male Female
/
/
❑
❑
Last name: First name: Middle initial:
Street address:
City: State: code:
Phone number (with area code): Email address:
–
–
Doctor, healthcare professional or supplier information
Provider or supplier name:
Provider NPI#:
Street address:
City: State: code:
Phone number (with area code): Email address:
–
–
Claim request (information must match your itemized bill)
Date of service (MM/DD/YYYY): Amount paid: Reimbursement type:
/
/
$
,
.
Description of procedure(s), service(s), or item(s) (include procedure code if available):
Signature
By signing and submitting this form, you certify that the information is true and correct.
________________________________________________________________________________ _________________________________________________________________
Member or authorized representative signature Date
❑ Medical ❑ Dental ❑ Vision
❑ Hearing ❑ Vaccine ❑ Other
click to sign
signature
click to edit
Proprietary
Important disclaimers
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.
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. 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. 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. 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. 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. 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.
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. 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. 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. 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. 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. 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. 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. 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. Ohio Residents: Any
Proprietary
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. 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. 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.
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. 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.
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. 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. 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. 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.
Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State
Medicaid programs. Enrollment in our plans depends on contract renewal. See Evidence of Coverage for a complete
description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by
location.
Aetna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex. ATTENTION: If you speak a language other than English, free language assistance
services are available. Visit our website at www.aetnamedicare.com or call the phone number on your member
identification card.
ESPAÑOL (SPANISH): ATENCIÓN: Si usted habla español, se encuentran disponibles servicios gratuitos de
asistencia de idiomas. Visite nuestro sitio web en www.aetnamedicare.com o llame al número de teléfono que se indica
en su tarjeta de identificación de afiliado.
繁體中文 (CHINESE): 請注意：如果您說中文，您可以獲得免費的語言協助服務。請造訪我們的網站
www.aetnamedicare.com 或致電您的會員卡上的電話號碼。
© 2020 Aetna Inc.
Y0001_NR_0009_10581d_2020_C 05/2020
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