Fillable Medical-claim-form Medical Claim Form

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Medical-claim-form Medical Claim Form

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The Medical-claim-form Medical Claim Form form is 2 pages long and contains:

  • 3 signatures
  • 22 check-boxes
  • 80 other fields

Country of origin: US
File type: PDF

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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 guilt
y 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 Resi
dents: 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 EMPLOYEE
1. Complete items one (1) through nineteen (19) in full.
2. Complete items twenty (20) through twenty-four (24) only if other medical coverage exists.
3. Be certain to sign the authorization to release information in block twenty-five (25).
4. If you wish to have your benefits for this claim paid directly to your physician or supplier, sign block twenty-six (26).
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 -
-date(s) of service(s)
condition being treated -
relationship to employee
type of service(s) rendered
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. Receipt must contain:
-
-
-
drug name
dose per/day
charge
purchase date
nature of illness or injury
strength
-
-
-
-
-
-
prescription number
quantity
physician's name
- pharmacy name/address
This information can be copied from the prescription bottle or box.
8. Retain copies of your bills for your record.
9. Refer to the back of your ID card for claim mailing address.
TO THE PHYSICIAN OR SUPPLIER
1. Complete items twenty-seven (27) through forty-six (46) in full.
2. If the employee 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 employee.
GC-7 (10-16) N R-POD
Medical Benefits Request
Refer to the back of your ID card
for claim mailing address
TO BE COMPLETED BY EMPLOYEE
1. Employer's Name 2. Policy/Group Numbe
r
3. Employee's Aetna ID Numbe
r
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 Numbe
r
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 Gende
r
Male Female
15. Patient's Marital Status
Married Single
16. Is patient employed?
No Yes
17. Name & Address of Employe
r
18. Is claim related to an accident?
No Yes If Yes, date time am pm
19. Is claim related to employment?
No Yes
20. 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
21. If Yes, list policy or contract holder, policy or contract number(s) and name/address of
insurance company or administrator:
22. Member’s ID Numbe
r
23. Member’s Name 24. Member’s Birthdate (MM/DD/YYYY)
25. 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
26. 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
27. Date of Illness (first symptom) or injury
(accident) or pregnancy (LMP)
28. Date first consulted you for this condition 29. If patient has had similar illness or injury, give dates 30. If an emergency check here
emergency
31. Date patient able to return to work 32. Date of total disability
from through
33. Date of partial disability
from through
34. Name of referring physician (e.g., Public Health Agency) 35. For services related to hospitalization give hospitalization dates
admitted discharged
36. Name & address of facility where services rendered (if other than home or office)
37. Diagnosis or nature of illness or injury (please indicate primary and secondary)
1.
2.
3.
4.
38. Procedures, Medical Services, Supplies Furnished
Date of
Service
Place of
Service*
Procedure Code
Identify** Description of Service
Type of
Service t Charges Days or Units Diagnosis Code tt
39. Physician's Name & Address (include ZIP Code) 40. Telephone Number
( )
41. 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.
42. Patient Account Number
43. Total charge $
Amount paid $
Balance due
$
44. Physician's or Supplier's Signature 45. National Provider Identifier 46. Date
* Place of Service Codes:
1 - (IH) - Inpatient Hospital
2 - (OH) - Outpatient Hospital
3 - (O) - Office Visit
4 - (H) - Patient Home
5 - - Day Care Facility (PSY)
6 - - Night Care Facility (PSY)
7 - (NH) - Nursing Home
8 - (SNF) - Skilled Nursing Facility
9 - - Ambulance
0 - (OL) - Other Location
A - (IL) - Independent Laboratory
B - - Other Medical Surgical Facility
C - (RTC) - Residential Treatment Center
D - (STF) - Specialized Treatment Facility
tType of Service Codes:
1 - Medical Care
2 - Surgery
3 - Consultation
4 - Diagnostic X-Ray
5 - Diagnostic Laboratory
6 - Radiation Therapy
7 - Anesthesia
8 - Assistance at Surgery
9 - Other Medical Service
0 - Blood or Packed Red Cells
A - Used DME
M - Alternate Payment for Maintenance Dialysis
Y - Second Opinion on Elective Surgery
Z - Third Opinion on Elective Surgery
** Please Use Current Procedural Terminology Codes For Surgery ttPlease Use ICD Code For Discharge Diagnosis
GC-7 (10-16) N Page 2 of 7
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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 14
462, 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 believ
e 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).
GC-7 (10-16) N Page 3 of 7
TTY:
711
For
lan
guage assistance
in
your
lan
g
ua
ge
call the number listed
on
your ID card at no cost. (English)
Para obtener asistencia lingliistica en espaiiol,
Harn
e sin cargo al nfunero que figura en
su
tatjeta de
identificaci6n. (Spanish)
Pour une assistance linguistique en fran¥ais appeler le numero indique sur votre carte d'identite sans frais.
(French)
Para
sa
tulong
sa
wika na na
sa
Tagalog, tawagan ang nakalistang numero
sa
iyong ID
card
nang walang
bayad. (Tagalog)
T'
aa
shi shizaad k'ehjf bee shika a'doowol nfnizingo Dine
k'e
hji naaltsoos bee atah nfliigo nanit
in
fgii
beesh bee hane'e bikaa' aa
ji
'
t'aajifk'e
h61ne'. (Navajo)
Benotigen Sie Hilfe oder Informationen
auf
Deutsch? Rufen Sie kostenJos die
auflhrer
Versicherungskarte aufgefuhrte Nummer an. (German)
Per asistence ne gjuhen shqipe telefononi falas ne numrin e regjistmar ne katten tuaj
te
identitetit (ID).
(Albanian)
ll:iqt{ll gm.gwpl:ipwo
W2wl.J.gm.p-JWU
(hwjl:ipl:iu) 9.wuqwhwpl:ip
p-)nJ.I!
uz
tJ.wo
t
c\l:ip
10
pwp
tnp
wnwug
quntJ.:
(Armenian)
Niba urondera uwugufasha mu Kimndi, twakure ku busa ku inomero iri ku ikarata karangamuntu yawe.
(Bantu-Kirundi)
Alang
sa
pag-abag
sa
pinulongan
sa
(Binisayang Sinugboanon) tawga ang
numero
nga gilista
sa
imong
kard
sa
kailhanan nga
walay
bayad. (Bisayan-Visayan)
<n~"'l"P.T
\5"Pil
~~fl~litl
~
~~
~
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~
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(Bengali-Bangala)
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068
Go:CD'J:~~C(lc}:{>JoS~G.5f
~Ju
(Burmese)
Per rebre assistencia en (catala),
truqui
al
numero
de
telefon
gratui"t
que
apareix a
Ia
seva targeta
d'identificaci6. (Cata lan)
Para
ayuda gi
fino'
(Chamoru), agang I
numiru
ni mangaige gi iyo-mu
'10
card', sin gastu
..
(Chamorro)
GC-7 (10-16) N Page 4 of 7
8cl{lY8
'5-IOh.f.lc!U.A
.Ahc!USPc!UY
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8c!UY
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Afc!U.A
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hl"R8.
(Cherokee)
(Chahta) anumpa Y!i ape
Ia
a chi bvnna
hokmvt
chi
holisso kallo iskitini ma
holhtena
yvt
takanli.
Na
aivlli
keyu
hQ
ish 1 pfiya hinla. (Choctaw)
Tajaajila afaan Oromiffa argachuuflakkoofsota bilbilaa waraqaa eenyummaa keessan irra
jiran
irratti
bilisaan bilbilaa. (Cushite)
Bel
voor
tolk-
en
vertaaldiensten
in
het Nederlands gratis
naar
het nurnrner dat op uw identiteitskaart
verrneld staat. (Dutch)
Pou
jv•;enn asistans nan lang ¥Jey01
.i~.yisyen,
rele
ro.ime\vo
a
yo
endike nan kat idantifikasyon
ou
gratis.
(French Creole)
fta
y/..wa<nKJj
polj8eta
ara
EllT]VtK<i
Kaf..eare xwpi'
XPEW<JT]
rov apt81!6 nov avayp<i<perat
<JTT]V
K<ipra
avayvwptaTJ,. (Greek)
No
ke
kokua
ma
ka
'olelo
Hawai'i e kahea aku i ka helu kelepona ma kau kaleka
ID,
kaki
'ole
'ia
keia
kokua
nei. (Hawaiian)
Yog
xav
tau
kev
pab txhais Ius Hrnoob
hu
dawb tau
rau
tus
xov
tooj ntawrn koj dairn npav. (Hrnong)
Maka
enyernaka
as\}S\1
na Igbo
kpQQnQrnba
edep\}tara
na
kaadj
ID
gj na akw\lghi
\}gWQ
9 b\lla. (Ibo)
Para iti tulong ti pagsasao iti pagsasao tawagan ti nurnero a nakalista iti
ID
card
yo
nga
awan ti bayadan
yo. (Ilocano)
Untuk
bantuan dalam bahasa Indonesia, silakan
hubungi
nomor
yang
tercantum
di kartu
ID
And a tanpa
dikenakan biaya. (Indonesian)
Per ricevere assistenza linguistica
in
italiano, puo chiarnare gratuitarnente il nurnero riportato sulla Sua
scheda identificativa. (Italian)
B
:;t;;~~-ct.iM
~
;:':ffi"~O):tJii,
ID:i:J-
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l::i;cti
~;h.
n'
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(Japanese)
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0
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:JfC:OII
4'~§
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~£ft':i:Q~
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(Korean)
GC-7 (10-16) N Page 5 of 7
'BE
m
ke
gbo-kpa-kpa
dye
qe
'Bas5~
wuquiin
WEE,
qa
n~oa
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J
ceea
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ni
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k3E
66
pfdyi.
(Kru-Bassa)
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,
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Ui
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~u
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e>9uh u t
O€J
UC:::J€J
€11
t
Ul.
(Laotian)
Nan
biik
jipaFi ilo Kajin Majol
kwon
kallok
niimba
eo
ej
walok
ilo kaat in
IDeo
am
ejjelok
wiinan.
(Marshallese)
Ohng palien
sa
was en soun kawewe ni
omw
lokaia
Po
nape koahl
nempe
me sansal
pohn
noumw
ID
koard ni sohte isais. (Micronesian-Pohnpeian)
WLH1Ucl
~
lli?il
hll
cJ1
,..,
hll
t1@
J
~B'i!JWI;;)
ffiHtru
8
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ruHlS
ts"i
ulhJ~
Wlefl
ru
cuHl
Cl
nJUWl;!Rt~
lliii"i
iRRiRt\";j 9
(Man-Khmer,
Cambodian)
Ten kuoony e thok e
ThuolJ.iiilJ
col akuen ci reec e kaaddu k5u kecin ay6c.(Nilotic-Dinka)
For spriikassistanse pa norsk, ring nurnrneret pa ID-kortet ditt kostnadsfritt. (Norwegian)
Fer Helfe in Deitsch,
ruf
die Fonnurnrner aa die
uff
dei ID Kaarde iss. Es Aarufkoschtet nix.
(Pennsylvania Dutch)
~I.";~
'-"W
w...ol
o.l.ol
W
~t..,.,ll.S;
w.J\£
<£J.J
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(Persian)
Aby uzyskac pornoc w j<;zyku polskirn, zadzwon bezplatnie pod nurner podany na karcie ID. (Polish)
Para obter assistencia linguistica ern portugues ligue para o nurnero gratis listado no seu cartao de
identifica9ao. (Portuguese)
Pentru asistenlii lingvisticii
in
rornane~te
telefonati Ia nurniirul gratuit indica! pe cardul dvs.
de
rnernbru de
Ia
Aetna. (Romanian)
GC-7 (10-16) N Page 6 of 7
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pyccKO.SI3blqHQfO
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yKa3aHHOMY
B Barnei\ ID-KapTe
YIIOCTOBepeHIIl!
JIWIHOCTH.
(Russian)
Mo
fesoasoani tau gagana I le Gagana Samoa
vala'au
le nurnera o
lo'o
lisiina I Juga o !au pepa
IDe
aunoa
rna se totogi. (Samoan)
Zajezicnu
pornoc
na
hrvatskornjeziku
pozovite besplatan broj naveden na poledini Vase identifikacijske
kartice. (Serbo-Croatian)
Fii
yo
on he5u balal e ko yowitii e haala Pular noddee e dii nurnero
ji
lintaadi ka kaydi dantite rnon. Njodi
woo fawaaki on. (Sudanic-Fulfulde)
Ukihitaji usaidizi katika lugha
ya
Kiswahili piga sirnu
kwa
narnbari iliyoorodheshwa kwenye
Kitarnbulisho chako hila rnalipo. (Swahili)
Kapau
'oku
fierna'u ha tokoni
'i
he
lea
faka-Tonga telefoni ki he fika
'oku
lisi
'i
ho'o
kaati
ID
'o
'ikai ha
t6t6ngi (Tongan)
Ren
aninnisin chiaku
ren
(Kapasen Chuuk) kopwe kekkeeri ena narnpaan tengewa aa rnakketiw
w66n
nournw ena cheen taropween
ID
nge esapw kame ngonuk. (Trukese)
(Dilde) dil yard1rn i9in
say1
hi9bir iicret 6derneden kirnlik karl! listelenen diyoruz. (Turkish)
ll.(o6
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(Vietnamese)
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(Yoruba)
GC-7 (10-16) N
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