How to File a Dental Claim with Aetna Medicare

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Are you a participant in Aetna Medicare? If so, you may want to file a dental claim with Aetna Medicare, but you do not know what you have to do to file it. You are able to read the explanation below about filing a dental claim with Aetna Medicare.

The Time For Filing a Claim with Aetna Medicare For Employers and Organizations

According to the Aetna Medicare site, for employers and organizations who are members of HMO, Aetna Open Access HMO, Aetna Open Access Elect Choice EPO members, generally they do not have to file claims. If they use in-network services, claim forms are not required unless they have paid for emergency out-of-area urgent care. It is also explained that network providers submit claims on behalf of the members. The process of claim submission is paperless from the member’s point of view when the member uses network providers.

For QPOS, USAccess, Managed Choice POS, Aetna Open Access Managed Choice POS members, they are not required to submit claim forms if they use in-network services and network providers submit claims on behalf of the members. The process of claim submission is paperless from the point of view of the member when the member uses network providers.

If the members use non-network or out-of-area services, they need to submit claims by using Aetna standard claim form for the first submission. After that, the member may be able to use a simplified claim submission process where the process involves using a tear-off, mini claim form which can be found on the back of Aetna Explanation of Benefits (EOB).

Aetna Medicare Medical Claim Reimbursement

You are able to ask for reimbursement of a covered medical service, dental service, eyewear, hearing aid, vaccine or fitness reimbursement you paid a doctor, healthcare professional, or service provider who did not bill us directly by filling out this form at here.

However, you are not able to use the form above for prescription drug claim reimbursements. If you need a prescription drug claim form, you are able to access AetnaMedicare.com or you are able to call the member services number which can be found on your member ID card.

How to fill out the form above for claiming a reimbursement? As you are able to read earlier, you can claim a reimbursement from Aetna Medicare of a covered medical service and one of them is dental service. So, if you want to ask for or claim reimbursement for dental service, you are able to fill the form by completing each section. You have to print clearly in black ink only or you are able to type the information in the form online. After you fill out the form, then you need to sign and date the bottom of the form. As explained by Aetna Medicare, appointed representatives must have an Appointment of Representative form on file with the health plan, or you are able to submit one with the form above. An Appointment of Representative form can be found on AetnaMedicare.com.

After you complete the form, you may not know where you have to send it. You have to make copies of all of your receipts and itemized bills from your provider. You have to make sure that you include your Aetna member ID number on each receipt and bill. It is important for you to note that all materials which have been submitted will be retained by Aetna Medicare and these cannot be returned to you.

You are required to mail the completed form and your original receipts and itemized bills to the medical claims address which can be found on your Aetna member ID card. Alternatively, you are able to choose to fax the completed form, your original receipts and itemized bills to 1-866-474-4040.

It is important for you to note that you need to submit the form within 365 days from the date you received the service or item. Let’s say that your request is not complete. If it happens, the Aetna Medicare team will communicate to you on your monthly Explanation of Benefits and it will delay the process. Make sure that you provide the name of the individual practitioner who performed the service. If Aetna Medicare approves your request, it is able to take up to 45 days to send payment after they have all the required information.

The Way My Claims Are Reimbursed (Dental Preferred Provider Organization)

According to the Aetna Medicare website, here is the explanation about the way your claims are reimbursed (Dental PPO).

Certain services are offered by network dentists at a negotiated rate. Let’s say that you visit a network dentist. If so, you usually pay less out of pocket.

  • Let say that your plan has a deductible (a dollar amount you need to pay for covered expenses in a plan year). You need to meet the deductible before your plan covers your eligible dental expenses.
  • If you meet your deductible, you will pay a coinsurance amount (a percentage of covered expenses) at the time of service. You are able to see your plan documents to learn this amount.
  • Your claims may be submitted by your dentist for you.

How about out-of-network dentists? If you visit dentists who are not in the Aetna network, the dentists may bill you their normal fee for procedures. Your plan gives benefits using amounts that Aetna has set as the ‘recognized charge’ for each service in your geographic area. When Aetna sets the ‘recognized charge’, Aetna may consider other factors, including the prevailing charge in other areas. On Aetna Medicare site, it is also explained that the amount of Aetna ‘recognized charge’ does not suggest the fee of your dentist is not reasonable and proper.

You may find that your dentist bill you for the difference between his or her normal fee and Aetna’s’recognized charge’. This amount is not covered and it means that you need to pay it.

  • Your plan may have a deductible and the deductible is the dollar amount that you need to pay before your plan covers your eligible dental expenses.
  • A Coinsurance percentage or flat dollar amount may be paid by you which means that you will pay a portion of covered expenses at the time of service. You can see your plan documents for specific amounts.
  • You or your dentist is able to submit a claim form for reimbursement.

That’s the explanation that I got related to Aetna Medicare Dental Claim. If you feel that you need a clearer explanation, you are able to contact Aetna Medicare customer service.

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