Get Aetna Pa-13-04-02

Filling out the Aetna PA-13-04-02 application form is a crucial step for organizations seeking to contract with Aetna Better Health. This guide provides clear and supportive instructions to help you successfully complete the form online and ensure your information is submitted correctly.

Follow the steps to complete the Aetna PA-13-04-02 application online.

1. Press the ‘Get Form’ button to access the Aetna PA-13-04-02 application. This will allow you to view and edit the form online.
2. Begin by entering your business name and the corporate name along with the Tax Identification Number (TIN). Be sure to include any 'Doing Business As' (DBA) names if applicable.
3. Proceed to fill in the required identifiers, including your NPI number, Medicare number, Medicaid number, and any other IDs requested. Make sure to provide accurate effective dates where indicated.
4. Indicate whether your organization is accepting new Medicaid patients by marking 'Yes' or 'No'. Also, denote if your organization has undergone any ownership changes and provide the relevant dates and documentation if required.
5. Select the applicable boxes that describe your facility type. Circle the relevant accreditation or certification types and supply copies of any pertinent certificates.
6. In the section for unique services or information, include any additional details that may be important for Aetna Better Health to know about your organization.
7. Fill in your primary address details accurately, ensuring all contact information such as phone, fax, and email addresses are entered correctly.
8. Complete the payment information section, which needs to align with the information provided on your W-9 form. Be careful to provide accurate billing contact information.
9. Review the attestation section. This is where you certify the accuracy of the information provided. Ensure you provide your name, signature, title, and the date.
10. Once you have completed all sections of the form, make sure to save your changes. You may then proceed to download, print, or share the completed application form.

Take the next step and complete your application online today!