Contents
The Aetna International Claim Form serves as a crucial tool for members seeking reimbursement for various medical expenses. It is essential to complete this form accurately, as incomplete submissions can lead to delays in processing claims. Each family member requires a separate claim form, and members are advised to tape smaller receipts onto a full-size sheet of paper for clarity. The form covers a range of services, including medical, dental, maternity, vision, and wellness treatments, necessitating a thorough understanding of one’s policy documents to confirm coverage. Key sections of the form include member and patient information, details about any other health insurance coverage, and specific claim information that outlines the services received. It is important to provide a diagnosis or reason for treatment and include any necessary documentation, such as prescriptions or referrals. Members must also indicate their preferred method of reimbursement, whether through bank transfer or cheque, and complete a declaration to affirm the accuracy of the information provided. To ensure a smooth process, claims must be submitted within 180 days of the treatment date, emphasizing the need for timely and complete submissions.
Preview - Aetna International Claim Form
Aetna International Claim Form
Please submit this completed Claim form with itemized bills and receipts. A separate Claim Form is needed for each family
member. Please tape small receipts on a full size sheet of paper. Failure to complete all sections of this form may result in
claim processing delays.
Please Retain a Copy for Your Records
Policies issued in Hong Kong are issued by GAN Assurances IARD and administered by Aetna Global Benefits (Asia Pacific) Limited,
an Aetna Company. Aetna Global Benefits (Asia Pacific) Limited registered address: Suite 401-403, DCH Commercial Centre, 25
Westlands Road, Quarry Bay, Hong Kong. Insurance Registration No. 02905813.
GR-68747-3 HK (9-12) Page 1 of 2
Medical Dental Maternity Vision Wellness
Please refer to your policy documents to verify the cover available through your Plan.
Important Note: Please ensure Your Claim Form is completed in full and returned within 180 days of the Treatment date.
1. Member Information – Must be completed.
Policy Name Policy Number
Member's Name
Member's Date of Birth Member Aetna Identification Number
Street Address
City State/Province
Country Postal/ZIP Code
Member's Telephone Number Mobile Number
Member's E-Mail Address
2. Patient Information – Must be completed.
Patient's Full Name
Patient's Date of Birth Patient’s Aetna Identification Number
Gender Male Female Relationship Self Spouse Child Other
3. Other Health Insurance Coverage – Must be completed.
Do you hold any other insurance? No Yes Other Carrier Name
Other Insurance Policy Number Policy Holder Name
Please submit the relevant documents for the details if you get the reimbursement from other insurance for this claim submission.
4. Claim Information (Please include diagnosis or reason for treatment for each service received.)
• For services related to an accidental injury, details of the accident must be provided.
• For conditions that have required long term treatments, please provide details of when the symptoms and/or treatment began.
• Claims for prescribed drugs or medication should include a prescription from your general practitioner (GP) or medical specialist.
• Acupuncture, Podiatry, Chiropractic, Osteopath, Homeopath treatment and physiotherapy require a referral from your GP or
medical specialist.
• If you have insufficient space in any section, please provide full details on separate sheet.
Dates of
Services
Provider's (physician, clinic,
hospital, pharmacy, dentist)
Name and Address (If the
provider’s name and address is
on receipts, write “see receipts”)
Description of
Service/ Name of
Medication/ Device
(If hospital, state
Inpatient, Day Case
or Outpatient)
Diagnosis
(Reason for visit) Country of Claim
Currency
of Claim
Total
Charge
If the claim is for Maternity please indicate the expected due date of the pregnancy.
Please confirm if your pregnancy is a result of assisted conception/infertility treatment.
For dental claims, please indicate the related tooth and ensure itemized breakdown of services is included.
Were your injuries caused by an Accident? No Yes
If Yes, is it: Motor Vehicle Related?
No Yes, provide Accident Date Time AM PM
Work Related? No Yes, provide Accident Date Time AM PM
Please provide accident details on a separate sheet.
Please Retain a Copy for Your Records
Policies issued in Hong Kong are issued by GAN Assurances IARD and administered by Aetna Global Benefits (Asia Pacific) Limited,
an Aetna Company. Aetna Global Benefits (Asia Pacific) Limited registered address: Suite 401-403, DCH Commercial Centre, 25
Westlands Road, Quarry Bay, Hong Kong. Insurance Registration No. 02905813.
GR-68747-3 HK (9-12) Page 2 of 2
Member’s Name (For faxing purpose):
5. Summary of Payment Details – Must be completed.
Recurring Reimbursement Election – Please check one of the following options if you want to:
Receive future payments using the details provided below
Use the payment information provided below for this claim only
Use the payment details that we already have on file for you
Payment Information
Please select your preferred reimbursement method: Bank Transfer Cheque
(If no selection is made, the default method is cheque issued in the member’s name.)
Please indicate your preferred payment currency (If none is indicated, the default currency is US Dollar.)
Payee Name Specify if: Member Provider Employer
Claim Settlement Address (if different to Section 1):
Street
City State/Province Country
If you have selected Bank Transfer as your preferred payment method, the following information is required:
Bank Account Holder Name (as per Bank Statement)
Bank Account Number Sort Code/Branch Code
IBAN Code* Swift/BIC Code
IFSC/ABA/ US Routing Code
Bank Name
Bank Address (include Country)
Bank Telephone Number (include Country Code)
*The IBAN is mandatory for bank transfer claim payment transactions in certain countries, such as the United Arab Emirates (UAE).
This must be supplied if you are using a bank account in one of these countries. Members should check with their bank to confirm
any IBAN requirements.
The most efficient method of receiving your benefits reimbursement is via Bank Transfer. Please check with your bank
for help with providing the appropriate instructions to Aetna International.
6. Declaration – Must be completed.
I declare that, to the best of my knowledge, all the information provided on this claim form is truthful and correct. I understand that
Aetna will rely on the information provided as such. I agree and accept that this declaration gives Aetna, and its appointed
representatives, the right to request past, present, and future medical information in relation to this claim, or any other claim related
to the member/covered individual, from any third party, including providers and medical practitioners. I declare and agree
that personal information may be collected, held, disclosed, or transferred (worldwide) to any organization within the Aetna group,
its suppliers, providers and any affiliates.
Patient's Signature Date
(If patient is under 18 years of age, Parent or Guardian must sign.)
Important Note: Please ensure Your Claim Form is completed in full and returned within six months (180 days) of the Treatment date.
Failure to complete your form in full will result in the form being returned to you and will delay the processing of your claim. Please
note Aetna International is not responsible for any costs associated with the completion of this form or for any further information/
document requested by Us to assess Your claim. The issuing of this Claim Form is in no way an admission of liability.
Please refer to your Member Handbook under General Claims Information for In-Patient, Day-Patient, Out-Patient Treatment and
Pre-authorizations for all MRI and CT scans.
7. Additional Information
How to submit a Claim
Aetna International provides alternative methods of submitting a claim form to make it easier for our members, below are the listed options:
• Postal Submission
Aetna Global Benefits (Asia Pacific) Limited
Suite 401-403
DCH Commercial Centre
25 Westlands Road
Quarry Bay
Hong Kong
• Online Claim Submission for our members via our
secure portal
www.AetnaInternational.com
• Submit your claim via Fax attaching receipts and
referrals from your Medical Practitioner
+852-2866-2555
• Email Submission with copies of your receipts and
referrals from your Medical Practitioner
AsiaPacServ[email protected]
• For claim related queries please contact our 24 hour
Member Services helpline
+852-3071-5022
Document Specifics
| Fact Name | Details |
|---|---|
| Submission Requirement | Complete the Claim Form and attach itemized bills and receipts for processing. |
| Family Members | A separate Claim Form is required for each family member submitting a claim. |
| Receipt Submission | Small receipts should be taped to a full-size sheet of paper to avoid loss. |
| Claim Form Deadline | Submit the completed form within 180 days from the treatment date to avoid delays. |
| Member Information | Must include essential details such as Policy Number, Member's Name, and Contact Information. |
| Patient Information | Complete patient details are mandatory, including name, date of birth, and relationship to the member. |
| Other Insurance Coverage | If applicable, provide details of any other insurance coverage and related documents. |
| Claim Information | Include diagnosis or reason for treatment, and details for any long-term conditions. |
| Payment Method | Choose between Bank Transfer or Cheque for reimbursement, and specify the preferred currency. |
| Declaration | A declaration of truthfulness and consent for Aetna to request medical information is required. |
Aetna International Claim: Usage Instruction
Filling out the Aetna International Claim form requires careful attention to detail. Completing the form accurately helps ensure that your claim is processed without delays. Follow these steps to fill out the form correctly.
- Member Information: Fill in all required fields including your policy name, policy number, name, date of birth, Aetna identification number, address, and contact information.
- Patient Information: Provide the patient's full name, date of birth, gender, relationship to you, and their Aetna identification number.
- Other Health Insurance Coverage: Indicate whether you have other insurance. If yes, provide the name of the other carrier, policy number, and policyholder's name. Attach relevant documents if you are seeking reimbursement from another insurance for this claim.
- Claim Information: Describe the services received, including the provider's name and address, diagnosis, and total charges. If applicable, include details about accidents or long-term treatments. For prescriptions, attach the relevant prescription documents.
- Summary of Payment Details: Choose your reimbursement method—bank transfer or cheque. If opting for bank transfer, provide all necessary banking details. Indicate your preferred payment currency and payee name.
- Declaration: Sign and date the declaration, confirming that all information is accurate. If the patient is under 18, a parent or guardian must sign.
- Additional Information: Review the submission options available for your claim, including postal, online, fax, or email submission. Ensure you keep a copy of the completed form for your records.
Learn More on Aetna International Claim
What information is required to complete the Aetna International Claim Form?
To complete the Aetna International Claim Form, you must provide detailed information in several sections:
- Member Information: This includes your policy name, policy number, personal details, and contact information.
- Patient Information: You need to specify the patient's full name, date of birth, gender, relationship to the member, and Aetna identification number.
- Other Health Insurance Coverage: Indicate whether you have other insurance and provide the necessary details if applicable.
- Claim Information: Describe the treatment received, including diagnosis, details of any accidents, and specifics about prescribed medications.
Completing all sections accurately is crucial to avoid delays in processing your claim.
How should I submit the Aetna International Claim Form?
You have several options for submitting your claim form:
- Postal Submission: Mail your completed form along with all required receipts to the designated address.
- Online Submission: Use the secure portal provided by Aetna Global Benefits to submit your claim electronically.
- Fax Submission: Send your claim via fax, including all relevant receipts and referrals.
- Email Submission: Email your completed form and attachments to the designated Aetna email address.
Choose the method that is most convenient for you, but ensure that all documents are included to facilitate a smooth process.
What happens if I do not submit the claim form within the required timeframe?
It is essential to submit your claim form within 180 days of the treatment date. Failure to do so may result in your claim being denied. Aetna International strictly adheres to this deadline, so timely submission is crucial. If you miss this window, you may need to cover the costs yourself.
What should I do if I have questions about my claim?
If you have questions or need assistance regarding your claim, Aetna International provides a 24-hour Member Services helpline. You can reach out to them for guidance on any aspect of your claim, including submission procedures or the status of your claim. Additionally, you can refer to your Member Handbook for more detailed information on claims and coverage.
Common mistakes
When filling out the Aetna International Claim form, many individuals make common mistakes that can delay the processing of their claims. One significant error is not completing all sections of the form. Each section, from member information to claim details, is crucial. Omitting any part may lead to unnecessary delays, as the form will be returned for completion.
Another frequent mistake involves the submission of receipts and bills. Many people fail to tape small receipts onto a full-size sheet of paper, as instructed. This oversight can complicate the review process, making it harder for Aetna to assess the claim accurately. Proper organization of documentation is essential to ensure a smooth submission.
Additionally, individuals often neglect to provide complete patient information. It’s not enough to list the patient’s name and date of birth; the relationship to the member must also be specified. This detail is vital for processing claims accurately, especially when multiple family members are involved.
Another common error is failing to include information about other health insurance coverage. If a member has additional insurance, this must be disclosed on the form. Not doing so can lead to complications, especially if reimbursement is sought from multiple sources. Providing the relevant details helps Aetna coordinate benefits effectively.
In the claim information section, some people forget to include a diagnosis or reason for treatment. This is particularly important for claims related to long-term treatments or specific conditions. Without this information, Aetna may not fully understand the context of the claim, leading to potential denials or requests for further information.
Lastly, many claimants overlook the declaration section. This part is crucial as it confirms that all provided information is truthful and complete. Failing to sign or date this section can result in processing delays. A clear declaration assures Aetna that they can rely on the information given, expediting the claims process.
Documents used along the form
When submitting an Aetna International Claim form, several other documents may be required to ensure a smooth claims process. Each of these documents serves a specific purpose and can help expedite the review and approval of your claim. Below is a list of commonly required forms and documents that often accompany the Aetna International Claim form.
- Itemized Bills and Receipts: These documents detail the services provided, including the cost for each service. They should be clear and organized, as they are essential for verifying the claim amount.
- Prescription Documentation: For claims involving prescribed medications, a copy of the prescription from your general practitioner or specialist is necessary. This helps confirm the legitimacy of the medication claim.
- Referral Letters: If the claim is for treatments like acupuncture, chiropractic care, or physiotherapy, a referral from a general practitioner or specialist is required to validate the treatment.
- Proof of Other Insurance: If you have other health insurance coverage, documentation from that insurer may be needed. This includes the policy number and any relevant details about the claim.
- Accident Reports: In cases where the claim is due to an accident, providing a detailed report of the incident can be crucial. This should include the date, time, and circumstances surrounding the accident.
- Bank Account Information: If you choose bank transfer as your reimbursement method, you must provide your bank account details, including the account holder's name and bank address.
- Claim Settlement Address: If the address for claim settlement differs from your member information, you must provide the correct address to ensure proper processing.
- Declaration Form: A signed declaration confirming the accuracy of the information provided in the claim form is essential. This document affirms that you understand Aetna may request further medical information if needed.
- Additional Information Sheet: If there are details that require more space than provided on the claim form, an additional sheet can be included to elaborate on those points.
By ensuring that all necessary documents accompany your Aetna International Claim form, you can help facilitate a smoother claims process and reduce the likelihood of delays. Always double-check that each document is complete and clearly labeled to assist the claims reviewers in their assessment.
Similar forms
The Aetna International Claim Form shares similarities with the Health Insurance Claim Form (CMS-1500), commonly used in the United States. Both documents require detailed patient and provider information, ensuring that claims are accurately processed. They necessitate the inclusion of diagnosis codes and treatment details, which are crucial for determining coverage eligibility. Additionally, both forms emphasize the importance of submitting claims within a specific timeframe, usually 180 days, to avoid delays in reimbursement. The structured format of each form aids in the efficient processing of claims by insurance companies.
Another document comparable to the Aetna International Claim Form is the Universal Claim Form, often used for various insurance claims. Like the Aetna form, it requires comprehensive member and patient information, along with detailed descriptions of services rendered. Both forms ask for the policy number and relevant identification numbers, ensuring that claims are linked to the correct accounts. The Universal Claim Form also includes sections for additional insurance coverage, mirroring the Aetna form's inquiry about other health insurance, which is vital for coordinating benefits.
The Medical Claim Form used by Medicare also bears resemblance to the Aetna International Claim Form. Both forms require specific patient demographics and detailed treatment information. They emphasize the need for itemized bills and receipts to support the claim, which is essential for verifying the services provided. Furthermore, both documents include sections for the provider’s information, ensuring that the claims are processed based on accurate provider data, which is crucial for reimbursement decisions.
Similarly, the Dental Claim Form used by dental insurance providers aligns closely with the Aetna International Claim Form. Both documents require detailed descriptions of services rendered, including specific tooth numbers for dental claims. They also necessitate itemized billing and provider information, ensuring that claims are substantiated with proper documentation. Each form stresses the importance of timely submission, reinforcing the need for members to adhere to deadlines to secure their benefits.
Lastly, the Workers' Compensation Claim Form is another document that shares features with the Aetna International Claim Form. Both forms require comprehensive information about the claimant, including details about the incident or treatment that led to the claim. They include sections for provider information and may require additional documentation, such as accident reports or medical referrals. Both forms aim to facilitate the processing of claims while ensuring that all necessary information is provided to avoid delays in reimbursement.
Dos and Don'ts
When filling out the Aetna International Claim form, there are important dos and don'ts to keep in mind. Following these guidelines will help ensure your claim is processed smoothly.
- Do complete all sections of the form fully.
- Do tape small receipts to a full-size sheet of paper.
- Do submit the claim within 180 days of the treatment date.
- Do provide detailed information about the diagnosis or reason for treatment.
- Don't leave any sections blank; incomplete forms may cause delays.
- Don't forget to include relevant documents if you have other insurance coverage.
- Don't submit your claim without retaining a copy for your records.
Misconceptions
- Misconception 1: One claim form is sufficient for the entire family.
- Misconception 2: The claim form can be submitted without itemized bills.
- Misconception 3: Claims can be submitted anytime after treatment.
- Misconception 4: The declaration section is optional.
This is incorrect. A separate claim form is required for each family member. This ensures that each member's information and claims are processed accurately and efficiently.
In fact, itemized bills and receipts are necessary to support the claim. Without these documents, the processing of the claim may be delayed or denied.
Claims must be submitted within 180 days of the treatment date. Failing to meet this deadline can result in the claim being rejected.
This section is mandatory. By signing the declaration, the member confirms that all information provided is accurate and allows Aetna to request further medical information if needed.
Key takeaways
Key Takeaways for Using the Aetna International Claim Form
- Complete all sections of the form. Missing information can delay your claim processing.
- Submit a separate claim form for each family member. This helps streamline the process.
- Return the form within 180 days of the treatment date. Timeliness is crucial for successful claims.
- Include itemized bills and receipts. Tape small receipts to a full-size sheet of paper for clarity.
- Choose your preferred payment method and currency carefully. Bank transfers are often the quickest way to receive reimbursement.