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Blank Aetna International Claim PDF Form

The Aetna International Claim Form is a document that allows members to request reimbursement for medical expenses incurred while receiving treatment abroad. To ensure a smooth claims process, it's essential to complete the form accurately and submit it along with itemized bills and receipts for each family member. For further assistance in filling out the form, please click the button below.

Article Guide

The Aetna International Claim Form is a crucial tool for members seeking reimbursement for various healthcare services, including medical, dental, maternity, vision, and wellness treatments. To ensure a smooth claims process, it is essential to submit the completed form along with itemized bills and receipts. Each family member requires a separate claim form, and small receipts should be taped to a full-size sheet of paper to avoid confusion. It is vital to fill out all sections of the form accurately, as incomplete submissions may lead to delays in processing. Members should also refer to their policy documents to confirm the coverage available under their plan. Timeliness is key; claims must be submitted within 180 days of the treatment date. The form captures important details such as member and patient information, other health insurance coverage, and specific claim information, including diagnosis and treatment details. Additionally, it allows members to select their preferred reimbursement method, whether by bank transfer or cheque. Finally, a declaration section ensures that all provided information is truthful, safeguarding both the member and Aetna’s interests.

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Aetna International Claim Form

Please submit this completed Claim form with itemized bills and receipts. A separate Claim Form is needed for each family member. Please tape small receipts on a full size sheet of paper. Failure to complete all sections of this form may result in claim processing delays.

Medical

Dental

Maternity

Vision

Wellness

Please refer to your policy documents to verify the cover available through your Plan.

Important Note: Please ensure Your Claim Form is completed in full and returned within 180 days of the Treatment date.

1. Member Information – Must be completed.


Policy Name								Policy Number
Member's Name
Member's Date of Birth								Member Aetna Identification Number
Street Address
City								State/Province
Country								Postal/ZIP Code
Member's Telephone Number								Mobile Number
Member's E-Mail Address


2. Patient Information – Must be completed.

Patient's Full Name
Patient's Date of Birth
Gender	Male	Female	Relationship

Patient’s Aetna Identification Number

Self

Spouse

Child

Other

3. Other Health Insurance Coverage – Must be completed.

Do you hold any other insurance?		No	Yes	Other Carrier Name
Other Insurance Policy Number				Policy Holder Name

Please submit the relevant documents for the details if you get the reimbursement from other insurance for this claim submission.

4.Claim Information (Please include diagnosis or reason for treatment for each service received.)

•For services related to an accidental injury, details of the accident must be provided.

•For conditions that have required long term treatments, please provide details of when the symptoms and/or treatment began.

•Claims for prescribed drugs or medication should include a prescription from your general practitioner (GP) or medical specialist.

•Acupuncture, Podiatry, Chiropractic, Osteopath, Homeopath treatment and physiotherapy require a referral from your GP or medical specialist.

•If you have insufficient space in any section, please provide full details on separate sheet.

		Description of
	Provider's (physician, clinic,	Service/ Name of
	hospital, pharmacy, dentist)	Medication/ Device
	Name and Address (If the	(If hospital, state
Dates of	provider’s name and address is	Inpatient, Day Case	Diagnosis		Currency	Total
Services	on receipts, write “see receipts”)	or Outpatient)	(Reason for visit)	Country of Claim	of Claim	Charge

If the claim is for Maternity please indicate the expected due date of the pregnancy.

Please confirm if your pregnancy is a result of assisted conception/infertility treatment.

For dental claims, please indicate the related tooth and ensure itemized breakdown of services is included.

Were your injuries caused by an Accident?	No	Yes
If Yes, is it: Motor Vehicle Related?	No	Yes, provide Accident Date	Time
Work Related?	No	Yes, provide Accident Date	Time

Please provide accident details on a separate sheet.

AM AM

PM PM

Please Retain a Copy for Your Records

Policies issued in Hong Kong are issued by GAN Assurances IARD and administered by Aetna Global Benefits (Asia Pacific) Limited, an Aetna Company. Aetna Global Benefits (Asia Pacific) Limited registered address: Suite 401-403, DCH Commercial Centre, 25 Westlands Road, Quarry Bay, Hong Kong. Insurance Registration No. 02905813.

GR-68747-3 HK (9-12)

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Member’s Name (For faxing purpose):

5. Summary of Payment Details – Must be completed.

Recurring Reimbursement Election – Please check one of the following options if you want to:

Receive future payments using the details provided below

Use the payment information provided below for this claim only

Use the payment details that we already have on file for you

Payment Information

Please select your preferred reimbursement method:

Bank Transfer

Cheque

(If no selection is made, the default method is cheque issued in the member’s name.)

Please indicate your preferred payment currency (If none is indicated, the default currency is US Dollar.)

Payee Name

Specify if:

Member

Provider

Employer

Claim Settlement Address (if different to Section 1):

Street

City

State/Province

Country

If you have selected Bank Transfer as your preferred payment method, the following information is required:

Bank Account Holder Name (as per Bank Statement)

Bank Account Number

Sort Code/Branch Code

IBAN Code*

Swift/BIC Code

IFSC/ABA/ US Routing Code

Bank Name

Bank Address (include Country)

Bank Telephone Number (include Country Code)

*The IBAN is mandatory for bank transfer claim payment transactions in certain countries, such as the United Arab Emirates (UAE). This must be supplied if you are using a bank account in one of these countries. Members should check with their bank to confirm any IBAN requirements.

The most efficient method of receiving your benefits reimbursement is via Bank Transfer. Please check with your bank for help with providing the appropriate instructions to Aetna International.

6.Declaration – Must be completed.

I declare that, to the best of my knowledge, all the information provided on this claim form is truthful and correct. I understand that Aetna will rely on the information provided as such. I agree and accept that this declaration gives Aetna, and its appointed representatives, the right to request past, present, and future medical information in relation to this claim, or any other claim related to the member/covered individual, from any third party, including providers and medical practitioners. I declare and agree

that personal information may be collected, held, disclosed, or transferred (worldwide) to any organization within the Aetna group, its suppliers, providers and any affiliates.

Patient's Signature		Date
(If patient is under 18 years of age, Parent or Guardian must sign.)

Important Note: Please ensure Your Claim Form is completed in full and returned within six months (180 days) of the Treatment date. Failure to complete your form in full will result in the form being returned to you and will delay the processing of your claim. Please note Aetna International is not responsible for any costs associated with the completion of this form or for any further information/ document requested by Us to assess Your claim. The issuing of this Claim Form is in no way an admission of liability.

Please refer to your Member Handbook under General Claims Information for In-Patient, Day-Patient, Out-Patient Treatment and Pre-authorizations for all MRI and CT scans.

7. Additional Information

How to submit a Claim

Aetna International provides alternative methods of submitting a claim form to make it easier for our members, below are the listed options:

• Postal Submission	• Online Claim Submission for our members via our
Aetna Global Benefits (Asia Pacific) Limited	secure portal
Suite 401-403	www.AetnaInternational.com
DCH Commercial Centre	• Submit your claim via Fax attaching receipts and
25 Westlands Road	referrals from your Medical Practitioner
Quarry Bay	+852-2866-2555
Hong Kong	• Email Submission with copies of your receipts and
	referrals from your Medical Practitioner
	[email protected]
	• For claim related queries please contact our 24 hour
	Member Services helpline
	+852-3071-5022

Please Retain a Copy for Your Records

GR-68747-3 HK (9-12)

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➤ PDF File

Form Specifications

Fact Name	Details
Claim Submission Requirement	A completed Aetna International Claim Form must be submitted along with itemized bills and receipts for each family member.
Claim Processing Timeframe	All claims must be submitted within 180 days from the date of treatment to avoid processing delays.
Member Information	Essential member details such as name, policy number, and contact information must be filled out accurately on the form.
Patient Information	Information about the patient, including their relationship to the member and gender, is mandatory for claim processing.
Other Insurance Coverage	If the member has other insurance, they must disclose this information and provide relevant documentation for reimbursement.
Payment Options	Members can choose their preferred reimbursement method, including bank transfer or cheque, and must specify the payment currency.
Submission Methods	Claims can be submitted via postal mail, online portal, fax, or email, providing flexibility for members in submitting their claims.

Aetna International Claim: Usage Guidelines

Completing the Aetna International Claim form accurately is essential for a smooth claims process. Ensure that all required sections are filled out completely and that you submit any necessary documents. Follow these steps carefully to avoid delays.

Fill out the Member Information section:
- Policy Name
- Policy Number
- Member's Name
- Member's Date of Birth
- Member Aetna Identification Number
- Street Address
- City
- State/Province
- Country
- Postal/ZIP Code
- Member's Telephone Number
- Mobile Number
- Member's E-Mail Address
Complete the Patient Information section:
- Patient's Full Name
- Patient's Date of Birth
- Gender (Male/Female)
- Relationship to the member (Self, Spouse, Child, Other)
- Patient’s Aetna Identification Number
Provide details in the Other Health Insurance Coverage section:
- Do you hold any other insurance? (Yes/No)
- Other Carrier Name
- Other Insurance Policy Number
- Policy Holder Name
Fill out the Claim Information section:
- Description of Provider's Name and Address
- Medication/Device Name
- Dates of Service
- Diagnosis
- Currency
- Total Charge
- Details for maternity claims, if applicable
- Indicate if injuries were caused by an accident (Yes/No)
Complete the Summary of Payment Details section:
- Select your reimbursement method (Bank Transfer or Cheque)
- Indicate payment currency
- Provide Payee Name
- Claim Settlement Address, if different from Section 1
- Complete Bank Transfer details, if applicable
Sign the Declaration section:
- Patient's Signature
- Date
Provide any Additional Information as necessary.

After completing the form, ensure you have all supporting documents ready for submission. You can submit your claim through various methods, including postal mail, online, fax, or email. Choose the method that works best for you and keep a copy of everything for your records.

Your Questions, Answered

What is the Aetna International Claim Form used for?

The Aetna International Claim Form is designed for members to submit claims for medical, dental, maternity, vision, and wellness services. It allows members to request reimbursement for covered expenses incurred during treatment. To ensure proper processing, members must provide itemized bills and receipts along with the completed form.

How do I complete the Aetna International Claim Form?

To complete the form, fill in all required sections accurately. This includes providing your personal information, details about the patient, and any other health insurance coverage you may have. Make sure to include specific claim information, such as the diagnosis or reason for treatment, and attach all relevant documentation. If needed, use a separate sheet for additional details. Remember, incomplete forms can lead to processing delays.

What is the deadline for submitting the claim form?

Members must submit the completed claim form within 180 days of the treatment date. It is crucial to adhere to this timeline to avoid potential denial of the claim. Ensure that all sections of the form are filled out completely to facilitate timely processing.

What payment methods are available for reimbursements?

Aetna offers several reimbursement methods. You can choose to receive payments via bank transfer or cheque. If you select bank transfer, you will need to provide specific banking details, including the account holder's name, account number, and bank address. If no method is chosen, Aetna defaults to issuing a cheque in the member’s name. Members should consider bank transfer for a more efficient reimbursement process.

How can I submit my claim form?

You have multiple options for submitting your claim form. You can send it via postal mail, use the online claim submission portal, or submit it via fax or email. If you choose fax or email, ensure that you attach all necessary receipts and referrals from your medical practitioner. For assistance, Aetna provides a 24-hour Member Services helpline for any claim-related queries.

Common mistakes

Incomplete Member Information: Many individuals overlook the requirement to fill out all sections under member information. Missing details like the member’s date of birth or identification number can lead to delays.
Neglecting Patient Information: Failing to provide complete patient information is a common mistake. Ensure that the patient’s full name, date of birth, and relationship to the member are accurately filled out.
Not Disclosing Other Health Insurance: Some people forget to indicate if they have other insurance coverage. This information is crucial for processing the claim correctly and may require additional documentation.
Insufficient Claim Information: Providing vague or incomplete descriptions of the treatment received can hinder the claim process. Include detailed information about diagnoses, treatment dates, and any relevant accident details.
Incorrect Payment Information: Many claimants fail to select their preferred reimbursement method or provide inaccurate banking details. This can result in payment delays or complications in receiving funds.

Documents used along the form

The Aetna International Claim form is a crucial document for members seeking reimbursement for medical expenses. However, several other forms and documents may accompany this claim to ensure a smooth processing experience. Below is a list of commonly used documents that can enhance the submission process.

Itemized Bills and Receipts: These documents provide a detailed breakdown of the services rendered, including dates, charges, and descriptions of the medical treatment. They are essential for verifying the amounts claimed and ensuring accurate reimbursement.
Referral Letters: For certain treatments, such as physiotherapy or specialist consultations, a referral letter from a general practitioner is necessary. This letter confirms the medical necessity of the treatment and helps streamline the claims process.
Other Insurance Documentation: If the member has other health insurance, relevant details must be provided. This includes the name of the other insurance carrier and the policy number, which helps Aetna coordinate benefits and avoid duplicate payments.
Medical Records: In cases of long-term treatment or complex medical conditions, relevant medical records may be required. These documents provide additional context and support for the claim, detailing the diagnosis and treatment history.

Including these documents with the Aetna International Claim form can significantly reduce processing time and enhance the likelihood of a successful claim outcome. Members are encouraged to review their submissions carefully to ensure all necessary information is included.

Similar forms

The Aetna International Claim Form shares similarities with several other documents commonly used in healthcare and insurance contexts. Below is a list of six documents that are similar to the Aetna International Claim Form, along with a brief explanation of each.

Health Insurance Claim Form (CMS-1500): This form is used by healthcare providers to bill Medicare and other insurers for services rendered. Like the Aetna form, it requires detailed patient information and itemized services provided.
Medicaid Claim Form (CMS-1500): Similar to the Health Insurance Claim Form, this document is utilized for billing Medicaid services. It also necessitates comprehensive patient details and service descriptions, mirroring the requirements of the Aetna form.
Personal Injury Protection (PIP) Claim Form: This form is used in auto insurance claims to cover medical expenses after an accident. It requires information about the accident, treatment received, and associated costs, paralleling the Aetna form's request for diagnosis and treatment details.
Workers' Compensation Claim Form: This document is submitted by employees to claim benefits for work-related injuries. Like the Aetna form, it demands information about the injury, treatment, and associated healthcare providers.
Dental Claim Form: Used by dental offices to submit claims to insurance companies, this form requires patient information and details of dental procedures performed. It shares similarities with the Aetna form, particularly in the need for itemized service breakdowns.
Vision Claim Form: This form is utilized for claiming vision-related expenses. It requires similar patient and treatment information, ensuring that claims are processed accurately, much like the Aetna International Claim Form.

Understanding these similarities can help streamline the claims process and ensure that all necessary information is provided accurately and efficiently.

Dos and Don'ts

When filling out the Aetna International Claim form, it's important to follow specific guidelines to ensure a smooth process. Here are ten things you should and shouldn't do:

Do complete all required sections of the form.
Don't forget to submit itemized bills and receipts along with your claim.
Do tape small receipts to a full-size sheet of paper.
Don't submit multiple claims on a single form; use a separate form for each family member.
Do provide accurate patient and member information, including dates of birth and identification numbers.
Don't leave any sections blank; incomplete forms may cause delays.
Do indicate if the claim is related to an accident and provide details if applicable.
Don't forget to sign the declaration section; your signature is essential.
Do check your policy documents to confirm coverage for the services claimed.
Don't wait too long to submit your claim; it must be returned within 180 days of treatment.

Misconceptions

Misconceptions about the Aetna International Claim form can lead to confusion and delays in processing claims. Here are ten common misconceptions, along with clarifications for each:

Only one claim form is needed for the entire family. Each family member must submit a separate claim form. This ensures that all information is accurately recorded for each individual.
Receipt submission is optional. It is essential to submit itemized bills and receipts along with the claim form. Without these documents, claims may be delayed or denied.
Claims can be submitted any time after treatment. Claims must be submitted within 180 days of the treatment date. Late submissions can result in denial of the claim.
All sections of the form are optional. Every section of the claim form must be completed. Incomplete forms can lead to processing delays.
Accident details are not necessary for all claims. If the claim relates to an accidental injury, specific details about the accident must be provided. This information is crucial for processing such claims.
There is no need to provide information about other health insurance. If the member has other insurance coverage, this information must be disclosed on the form. Aetna may need to coordinate benefits with the other insurer.
The payment method can be changed after submission. Once the claim is submitted, the selected payment method cannot be changed. Members should ensure they choose their preferred method at the time of submission.
Only medical claims can be submitted. The claim form is applicable for various types of claims, including dental, maternity, vision, and wellness services.
There is no need for a declaration signature. A declaration must be signed, affirming that all information provided is accurate. This step is crucial for the legitimacy of the claim.
Claims can only be submitted by mail. Aetna offers multiple submission methods, including online, fax, and email. Members can choose the method that is most convenient for them.

Understanding these misconceptions can help ensure a smoother claims process and prevent unnecessary delays. Always refer to the official guidelines and policy documents for the most accurate information.

Key takeaways

When navigating the Aetna International Claim form, understanding the essential components can streamline the process and enhance your experience. Here are some key takeaways to consider:

Complete All Sections: Ensure every section of the claim form is filled out completely. Incomplete forms can lead to processing delays, so take your time to provide accurate information.
Submit Within the Deadline: Claims must be submitted within 180 days from the treatment date. Mark your calendar to avoid missing this crucial deadline.
Provide Itemized Bills: Attach itemized bills and receipts to your claim form. For smaller receipts, tape them to a full-size sheet of paper to keep everything organized.
Choose Your Payment Method Wisely: Indicate your preferred reimbursement method clearly. Options include bank transfer or cheque. If you opt for bank transfer, ensure you provide all necessary banking details to avoid delays.