Transcription of Medicare Medical Claim Reimbursement Instructions
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Medicare Medical Claim Reimbursement Instructions
Proprietary When to use this form? 1. Fill out this form if you re asking for a Medical , dental, vision, hearing, or vaccine Reimbursement and you paid a doctor, healthcare professional, or service provider who did not bill us directly. 2. Don t use this form for prescription drug Claim reimbursements. Visit or call the member services number on your Aetna member ID card for a prescription drug Claim form. How to fill out this form? 1. Complete each section. Print clearly in black ink only, or type the information in the form online.
Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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