Form VA-16-04-02 "Provider Claim Reconsideration - Aetna" - Virginia

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Download Form VA-16-04-02 "Provider Claim Reconsideration - Aetna" - Virginia

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Aetna Better Health® of Virginia
9881 Mayland Drive
Richmond, VA 23233
AETNA BETTER HEALTH® OF VIRGINIA
Provider Claim Reconsideration form
Please complete the information below in its entirety and mail with supporting documentation
and a copy of your claim to the address listed at the bottom of this form. Questions regarding a
submission should be directed to Claims Inquiry/Claims Research at 800-279-1878. Please use
one form per member.
Date: ________________________
MEMBER INFORMATION
Member Name
Date of Service
Patient Account No.
Billed Amount
Member ID
Claim Number
PROVIDER INFORMATION
Provider Name
Tax ID Number
Practice Name
NPI Number
Street Address
Fax Number
City/State/Zip
Contact name
Provider Phone No.
Contact Number
SUBMISSION INFORMATION (See second page for detailed descriptions)
Claim Reconsideration
Examples of Appeals
Itemized Bill
Prior-Authorization Appeal
Duplicate Claim
Level of Care Appeal
Corrected Claim (note “corrected” on claim)
Medical Necessity Appeal
Other Appeal Request
Coordination of Benefits (note “corrected” on
claim)
If any of the above apply, and within 30 days of the
Proof of Timely Filing
event giving rise to the appeal, please “do not use
Claim/Coding Reconsideration
this form,” but fax or mail the Appeal and all
Other Claim reconsideration or Payment
supporting documentation clearly marked as
Dispute
“Filing an Appeal” to:
If you checked a box above, and within 365 days of
Aetna Better Health of Virginia
the date of service, please mail claim and all
Attn: Appeals
supporting documentation to:
9881 Mayland Drive
Aetna Better Health of Virginia
Richmond, VA 23233
Attn: Reconsiderations
-
or -
P.O. Box 63518
Fax: 866-669-2459
Phoenix, AZ 85082-3518
Please indicate the reason for resubmission and any pertinent details regarding your claim below.
www.aetnabetterhealth.com/virginia
VA-16-04-02
Aetna Better Health® of Virginia
9881 Mayland Drive
Richmond, VA 23233
AETNA BETTER HEALTH® OF VIRGINIA
Provider Claim Reconsideration form
Please complete the information below in its entirety and mail with supporting documentation
and a copy of your claim to the address listed at the bottom of this form. Questions regarding a
submission should be directed to Claims Inquiry/Claims Research at 800-279-1878. Please use
one form per member.
Date: ________________________
MEMBER INFORMATION
Member Name
Date of Service
Patient Account No.
Billed Amount
Member ID
Claim Number
PROVIDER INFORMATION
Provider Name
Tax ID Number
Practice Name
NPI Number
Street Address
Fax Number
City/State/Zip
Contact name
Provider Phone No.
Contact Number
SUBMISSION INFORMATION (See second page for detailed descriptions)
Claim Reconsideration
Examples of Appeals
Itemized Bill
Prior-Authorization Appeal
Duplicate Claim
Level of Care Appeal
Corrected Claim (note “corrected” on claim)
Medical Necessity Appeal
Other Appeal Request
Coordination of Benefits (note “corrected” on
claim)
If any of the above apply, and within 30 days of the
Proof of Timely Filing
event giving rise to the appeal, please “do not use
Claim/Coding Reconsideration
this form,” but fax or mail the Appeal and all
Other Claim reconsideration or Payment
supporting documentation clearly marked as
Dispute
“Filing an Appeal” to:
If you checked a box above, and within 365 days of
Aetna Better Health of Virginia
the date of service, please mail claim and all
Attn: Appeals
supporting documentation to:
9881 Mayland Drive
Aetna Better Health of Virginia
Richmond, VA 23233
Attn: Reconsiderations
-
or -
P.O. Box 63518
Fax: 866-669-2459
Phoenix, AZ 85082-3518
Please indicate the reason for resubmission and any pertinent details regarding your claim below.
www.aetnabetterhealth.com/virginia
VA-16-04-02
Aetna Better Health® of Virginia
9881 Mayland Drive
Richmond, VA 23233
Claim/Reconsideration Descriptions
Itemized Bill
All claims associated with an Itemized Bill must be broken out per Rev code to verify charges billed on the
UB match the charges billed on the Itemized bill. (Please attach I-Bill that is broken out by rev code with
sub-totals.)
Duplicate Claim
Review request for a claim whose original reason for denial was “duplicate.”
Provide documentation as to why the claim or service is not a duplicate such as medical records showing
two services were performed.
Corrected Claim
The corrected claim must be clearly identified as a corrected claim by writing or stamping “corrected” on
the claim itself.
Coordination of Benefits
Attach EOB or letter from primary carrier and forward to the claims department identifying as “corrected”
claim.
Proof of Timely Filing
For electronically submitted claims provide the second level acceptance report.
Refer to Proof of Timely Filing Requirements in your Provider Manual.
Claim/Coding Edit
Aetna Better Health of Virginia uses two (2) claims edit applications: Claim Check and iHealth. Please
refer to the Provider Manual on the Aetna Better Health of Virginia website
www.aetnabetterhealth.com/virginia for more information on claim editing.
Corrected claims must be received within 365 of the date on the first remittance advice. Please refer to
the Aetna Better Health of Virginia Provider Manual at www.aetnabetterhealth.com/virginia, Claims
and Reimbursement Procedures section for more information.
Appeals must be received within 30 days of the date of the incident causing the appeal. Please refer to
the Aetna Better Health of Virginia Provider Manual online at www.aetnabetterhealth.com/virginia.
www.aetnabetterhealth.com/virginia
VA-16-04-02
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