Medicare Claim Reimbursement Form (Page 2 of 2) in pdf

Provider you got the services from:

Provider’s name and address (Please include ZIP

Provider TIN (tax identification number)

code)

Provider telephone number

(

)

Member tips

Be sure to submit the completed form along with all necessary documents. If your request is incomplete, we’ll

return it and this could delay processing. Processing can take from four to six weeks once we have all the required

information.

Questions?

We’re here to help. If you have any questions about your claim, just give us a call at the number on your member

ID card.

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.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copayments, and restrictions may apply. Benefits, and/or co-payments/co-insurance may

change on January 1 of each year. See Evidence of Coverage for a complete description of plan benefits,

exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

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

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

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

或致電您的會員卡上的電話號碼。

Y0001_3032_9434a_NM 04/2017

Medicare Claim Reimbursement Form Page 2