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Aetna Medical Claim Form 1

This form provided by Aetna contains an instruction and a medical benefits request form.

Aetna Medical Claim Form 1
Aetna Medical Claim Form 1
5BMedical 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 Arkansas, District of Columbia, Louisiana, 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 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 may subject such person to criminal and civil penalties. 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 and willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly and 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
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 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 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.
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.
3BTO 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 - condition being treated - type of service(s) rendered
- date(s) of service(s) - relationship to employee
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 - purchase date - prescription number - pharmacy name/address
- dose per/day - nature of illness or injury - quantity
- charge - strength - physician's name
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 (9-10) I R-POD
Aetna Medical Claim Form 1
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