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Precertification Request Form for Non-Participating Providers - Aetna 2025

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The document outlines the process for submitting a precertification or preauthorization request for nonparticipating providers to Aetna. It specifies the required information from both the requesting provider and patient, including details about the services needed and reasons for choosing a nonparticipating provider. Additionally, it provides instructions on how to submit the form and includes a fraud statement warning against providing false information.

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Click ‘Get Form’ to open the Precertification Request Form in our editor.
Begin by filling out Section A, 'Requesting Provider Information.' Enter the provider's name, ID number, contact name, telephone and fax numbers, and the request date.
Proceed to Section B, 'Patient Information.' Input the patient's name, date of birth, Aetna ID number, address, and telephone number.
In Section C, 'Nonparticipating Provider Information,' provide details about the nonparticipating provider including their name, contact information, specialty or ID number, and whether the patient has seen this provider before.
Move to Section D for 'Reason for Nonparticipating Provider Request.' Clearly outline the services needed, diagnosis codes, procedure codes, and explain why these services can only be provided by this specialist.
Finally, complete Section E by signing and dating the form. Ensure all fields are filled accurately before submission.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (45 Votes)
2013	4.3 Satisfied (284 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I submit precertification to Aetna?

Please submit your request electronically through Availity at .availity.com or call 888-632-3862 or 1-800-624-0756 to initiate precertification.

How do I request an exception to my Aetna RX coverage?

How can I request precertification (or an exception to precertification)? You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386 (TTY: 711). You can log in to your member website and submit a request through the Contact Us feature.

What is the phone number for Aetna Medicare precertification?

Please call the appropriate number below and select the option for precertification: 1-888-MD-AETNA (1-888-632-3862) (TTY: 711) for calls related to indemnity and PPO-based benefits plans. 1-800-624-0756 (TTY: 711) for calls related to HMO-based benefits plans.

How do I get my 1095-B form from Aetna?

You can receive a copy of your Form 1095-B by going out to the Aetna Member Website in the Message Center under the Letters and Communications tab or by sending us a request at Aetna PO BOX 981206, El Paso, TX 79998-1206.

What happens if I dont get my 1095-B?

Some taxpayers may not receive a Form 1095-B or Form 1095-C by the time they are ready to file their tax return. While the information on these forms may assist in preparing a return, they are not required. Individual taxpayers should not wait for these forms and file their returns as they normally would.

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Do 1095-B forms have to be mailed?

Generally, the return and transmittal form must be filed with the IRS on or before February 28 if filing on paper (March 31 if filing electronically) of the year following the calendar year of coverage. You will meet the requirement to file if the form is properly addressed and mailed on or before the due date.

How do I find my 1095 form online?

How to find your 1095-A online Log into your Marketplace account. Under Your applications, select your 2024 application not your 2025 application. Select Tax Forms. Download all 1095-As.

Precertification Request Form for Non-Participating Providers - Aetna 2025

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How to use or fill out Precertification Request Form for Non-Participating Providers - Aetna with Our Platform

See more Precertification Request Form for Non-Participating Providers - Aetna versions

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Got questions?

How do I submit precertification to Aetna?

How do I request an exception to my Aetna RX coverage?

What is the phone number for Aetna Medicare precertification?

How do I get my 1095-B form from Aetna?

What happens if I dont get my 1095-B?

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Do 1095-B forms have to be mailed?

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