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Make edits, fill in missing information, and update formatting in US Legal Forms—just like you would in MS Word.

Download a copy, print it, send it by email, or mail it via USPS—whatever works best for your next step.

Sign and collect signatures with our SignNow integration. Send to multiple recipients, set reminders, and more. Go Premium to unlock E-Sign.

If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.

We protect your documents and personal data by following strict security and privacy standards.
Submitting Claims Claims received after 180 days will be denied for untimely filing.
Call: 855-597-2624 (TTY 711)
Call: 855-597-2624 (TTY 711)
Contact options for providers Medicare medical and dental plans: 1-800-624-0756 (TTY: 711) Non-Medicare plans (includes individual & family plans): 1-888-632-3862 (TTY: 711) Non-Medicare dental plans: 1-800-451-7715 (TTY: 711) Supplemental plans: 1-888-772-9682 (TTY: 711) Worker's compensation: 1-800-238-6288 (TTY: 711)
Aetna offers group health insurance plans in all 50 states and in terms of membership is the third largest health insurer in the United States behind United Healthcare and Anthem Blue Cross. In California, Aetna ranks sixth in number of members among health insurance companies.
Need help? Contact your agent for personalized help. You may also call Aetna CVS Health at (866) 901-2922 or Covered California at (800) 300-1506.
Aetna Signature Administrators® is the brand name for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Aetna Inc. Since November 28, 2018, the company has been a subsidiary of CVS Health. Aetna Inc. Aetna's headquarters in Hartford, Connecticut.
Use the CPT Code 99404 in order to indicate the sessions is billed under EAP.
EAP claims should be submitted through Provider Express or on a CMS-1500 claim form using the standard "HJ" modifer in section 24D.