Aetna referral form 2026

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The document is an Aetna Managed Dental Specialty Referral Form for Direct Referral to participating Specialty Dentists. It outlines the necessary information required from employees and patients, including personal details, insurance coverage, and referral specifics for various dental specialties such as endodontics, oral surgery, pediatrics, periodontics, and orthodontics. The form emphasizes the need for prior approval for certain procedures and includes instructions for submitting claims and referrals.

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Click ‘Get Form’ to open the Aetna Referral Form in the editor.
Begin by filling out Part I, which includes Employee Information. Enter the employee's name, member identification number, home address, and contact details. Ensure all fields are completed accurately.
In Part II, if applicable, provide the dependent's name and date of birth. Indicate their gender and dependent status (spouse or child). If it's a child, confirm their dependency for support.
Proceed to Part III where you will need to enter information about the referring dentist and the specialist they are referring to. Specify whether the referral is in-network or out-of-network and provide any necessary rationale.
Complete the procedures section by indicating the primary reason for referral and any specific procedures that require prior approval. Be sure to include any required documentation as indicated on the form.
Finally, review all sections for accuracy before signing. Ensure both patient and referring dentist signatures are included where necessary.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (86 Votes)
2014	4.3 Satisfied (21 Votes)

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How can I sign my aetna specialist referral form pdf online?

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How many months is a referral good for?

A referral is a letter from your doctor to another health professional or health service. Most referrals are from GPs to specialists and last for 12 months. If you have a referral, Medicare should cover part of the costs for further tests or treatment.

What is the timely filing limit for Aetna?

Timely Filing Limits of Different Insurance Companies Insurance CompanyTimely Filing Limit for Initial Claim (From the date of service) Aetna Better Health 180 Days Aetna Better Health Kids 180 Days Ambetter 180 Days AvMed 1 Year21 more rows

Does Aetna allow retro referrals?

You may FAX your physical health authorization request to 1-844-227-9205. You may submit retrospective review requests for services requiring authorization on members that are retro actively eligible to 1-844-227-9205.

aetna specialty referral form

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How long is an Aetna referral good for?

Referrals are valid for 60 days as long as the individual remains an eligible member of the plan. In plans without out-of-network benefits, coverage for services from non-participating providers requires prior authorization by Aetna in addition to a special non-participating referral from the .

Do you need a referral with Aetna Select Open Access?

And you do not need a referral when you visit one. You dont have to choose a primary care physician () either, but you may want to. Thats because PCPs do more than give you a checkup. They know you, your medical history, and they can help guide you and direct your care.

Does Aetna Medicare require referrals?

For some services, your is required to obtain prior authorization from Aetna Medicare. Youll need to get a referral from your for covered, nonemergency specialty or hospital care, except in an emergency and for certain direct access service. There are exceptions for certain direct access services.

Does Aetna require a referral for dermatology?

Verify your plan: Confirm your coverage details by checking your policy documents or calling the number on the back of your Aetna ID card. Obtain a referral if needed: For HMO plans, get a referral from your primary care provider () for dermatology services; PPO plans typically do not require referrals.

Why would Aetna deny a claim?

The treating physician is out of network or out of plan. The claim filed was for a medical condition that isnt authorized or covered. Medical treatment or procedure is investigational or experimental. The policyholder misinterpreted something in their original application.