Form Ne-14-06-67 - Aetna Provider Claim Resubmission/reconsideration Form

Provider Claim Resubmission /Reconsideration Form

Mail to:

From: (contact)

Aetna Better Health of Nebraska

Attention: Claims Resubmission/Reconsideration

P.O. Box 63188

Phoenix, AZ 85082

Phone:

Corrected Claim

Reconsideration

Required Information

Member Name

Member ID #

Date(s) of Service

__ Remittance Advice Date:

Amount Billed:

Amount Paid:

Claim Number(s)

Providers have 180 days from the date of denial/processing to correct and resubmit claims. For timely filing

reconsiderations, refer to Aetna Better Health® of Nebraska’s criteria to initiate a review to override timely filing in

the Provider Handbook. Please allow approximately 30 days for processing.

Please use the space below to supply any other necessary information, along with your attachments, to enable a

through reconsideration.

Sender

Date

________

NE-14-06-67

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Parent category: Business