Provider Disputes and AppealsOhioMedicare Advantage 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Member Name and Member ID # in the designated fields. This information is crucial for identifying the claim being disputed.
3. Fill in the Date(s) of Service Denied and Claim Number. Ensure these details match the notification you received regarding the denial.
4. Provide the Date of Notice of Action, which indicates when you were informed about the claim denial.
5. Attach any necessary documentation such as operative notes, medical notes, office notes, or ER notes that support your appeal. Use our platform’s attachment feature for convenience.
6. Complete the Provider Name and Contact Person fields, along with their Phone Number and Address to ensure Aetna can reach you easily.
7. Finally, sign and date the form at the bottom to validate your request for a formal appeal.

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