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

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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.
Aetna Inc. Since November 28, 2018, the company has been a subsidiary of CVS Health. Aetna Inc. Aetna's headquarters in Hartford, Connecticut.
Virginia Anti-Subrogation Statute for Health Insurance Payments (Code Section 38.2-3405) Virginia's anti-subrogation rule states that a health insurance company may not seek indemnification from its insured.
It states that a subrogated insurance company standing in the shoes of its insured cannot bring a subrogation action against or sue its own insured.
If you've had a health treatment or disability claim denied by Aetna, it could be because: The procedure is considered cosmetic (not medically necessary) Your doctor is out of network or doesn't participate in the plan. Your plan doesn't cover your medical condition.
Use red drop on UB-04 paper forms only. Replacement/corrected claims require a Type of Bill with a Frequency Code “7” (field 4) and claim number in the Document Control Number (field 64). Enter all required data. All patient details are required (ID number with prefix, last name, first name, and date of birth).
A corrected claim is a replacement of a previously submitted claim. Previously submitted claims that were completely rejected or denied should be sent as a new claim.
Within 180 calendar days of the initial claim decision.
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).
Signature Advantage is a Special Needs plan that covers all the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D). If you or your loved one is eligible, Signature Advantage may be the extra benefit you need to maintain and enhance your health and well-being.