Aetna GC-1652 (Formerly GC-1360) 2014 free printable template

Commercial Prescription Drug Claim Form Aetna Member Number claim cannot be processed without number Aetna Pharmacy Management PO Box 52444 Phoenix AZ 85072-2444 FAX 1-888-472-1128 Group Number If you are enrolled in Medicare check here Employee Birthdate MM/DD/YYYY Employee Name First Middle Last Employee Address Street City State ZIP Code Company Name Address Street City State ZIP Code Employee Signature Telephone Number Date Prescription s wer...

How to fill out Aetna GC-1652 Formerly GC-1360

How to fill out Aetna GC-1652 (Formerly GC-1360)

1. Begin by gathering the necessary personal information, including the patient's name, date of birth, and Aetna identification number.
2. Fill in the policyholder's details if different from the patient, including their name and relationship to the patient.
3. Indicate the type of claim being submitted and the specific dates of service for the provided medical care.
4. Provide a detailed description of the services rendered, including any relevant diagnosis codes.
5. Attach copies of all applicable medical bills, receipts, and any other related documentation to support the claim.
6. Review the completed form for accuracy and completeness before submission.
7. Submit the form and all attachments as instructed, either by mail or electronically through the Aetna claims portal.

Who needs Aetna GC-1652 (Formerly GC-1360)?

1. Patients who have received medical services covered under their Aetna insurance and are seeking reimbursement.
2. Healthcare providers who are filing claims on behalf of their patients to obtain payment for services rendered.
3. Policyholders who need to report a claim for an eligible expense incurred under their Aetna health plan.

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What is Aetna GC-1652 (Formerly GC-1360)?

Aetna GC-1652 (Formerly GC-1360) is a specific form associated with claims submission or reporting for Aetna insurance. It is used for processing certain types of claims and ensuring compliance with Aetna's billing requirements.

Who is required to file Aetna GC-1652 (Formerly GC-1360)?

Providers and healthcare professionals who submit claims associated with Aetna insurance plans are required to file Aetna GC-1652 (Formerly GC-1360). This may include hospitals, individual practitioners, and outpatient facilities.

How to fill out Aetna GC-1652 (Formerly GC-1360)?

To fill out Aetna GC-1652 (Formerly GC-1360), you need to carefully follow the form's instructions, including entering the patient's information, insurance details, service rendered, and any pertinent coding. Make sure to double-check for accuracy to avoid delays in processing.

What is the purpose of Aetna GC-1652 (Formerly GC-1360)?

The purpose of Aetna GC-1652 (Formerly GC-1360) is to facilitate the proper reporting and submission of claims for reimbursement by Aetna, ensuring that healthcare providers are compensated for the services they deliver.

What information must be reported on Aetna GC-1652 (Formerly GC-1360)?

Information that must be reported on Aetna GC-1652 (Formerly GC-1360) includes, but is not limited to, the patient's details, provider information, diagnosis codes, procedure codes, date of service, and any additional documentation required for the claim.