Get Aenta Gr-69140 2016

This guide provides a detailed, user-friendly approach to completing the AENTA GR-69140 form online. Designed for both experienced users and those new to digital forms, this guide will walk you through each section to ensure you submit your complaint or appeal correctly.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the AENTA GR-69140 online and open it in your browser.
2. Enter today's date in the designated field at the top of the form. This helps Aetna track the timing of your request.
3. Provide the member’s ID number, which can be found on the member's ID card. This is crucial for identifying the individual associated with the complaint or appeal.
4. Select the plan type, indicating whether it is for medical or dental services.
5. Fill in the member’s first and last name as they appear on the ID card.
6. Include the optional member's group number if available, as it can assist in processing.
7. Input the member’s birthdate in the specified format (MM/DD/YYYY). This information verifies the member's identity.
8. Fill out the provider’s name along with their Tax Identification Number (TIN) or National Provider Identifier (NPI) as applicable.
9. Provide the provider group name if relevant, followed by the contact person's name and their title.
10. Enter the contact address where resolution correspondence should be sent. Ensure this is accurate for smooth communication.
11. List the contact phone number, fax number, and email address for follow-ups regarding your request.
12. Provide the claim ID number(s), reference number/authorization number, initial denial notification date, and service date to support your appeal.
13. Include the reconsideration denial notification date along with the CPT/HCPCS/service being disputed. This helps Aetna address your concerns accurately.
14. In the explanation of your request field, detail the basis of your complaint or appeal. Use additional pages if necessary, ensuring clarity in your position.
15. Attach any supporting documents, including medical records, to strengthen your appeal.
16. Once you have completed all sections, save your changes. You can download, print, or share the AENTA GR-69140 form as needed.

Complete your AENTA GR-69140 form online today for efficient processing of your appeal or complaint.