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Aetna Student Health Claim Form

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Medical Benefits Request

Refer to the back of your ID card for claim mailing address.

TO BE COMPLETED BY EMPLOYEE

1. Employer's Name
 2. Policy/Group Number
3. Employee's Aetna ID Number
 4. Employee's Name
 5. Employee's Birthdate (MM/DD/YYYY)
6. Active Retired
Date of Retirement
 7. Employee's Address (include zip code)
 8. Employee's Daytime Telephone Number
9. Patient's Name
 10. Patient's Aetna ID Number
 11. Patient's Birthdate (MM/DD/YYYY)
12. Patient's Relationship to Employee
Self Spouse Child Other 		13. Patient's Address (if different from employee)
 14. Patient's Sex
Male Female
15. Full Time Student
No Yes 		16. Patient's Expected Graduation Date
 17. Name of School
18. Patient's Marital Status
Married Single 		19. Is patient employed?
No Yes 		20. Name & Address of Employer
21. Is claim related to an accident?
No Yes, if yes, date ___ time ___ a.m. ___ p.m. 		22. Is claim related to employment?
No Yes 		23. Are any family members covered by another group plan?
No Yes
24. If yes, list policy or contract holder, policy or contract number(s) and name/address of insurance company or administrator
 25. Member's ID Number
 26. Member's Name
27. Member's Birthdate (MM/DD/YYYY)
 28. To all providers of health care:

You are authorized to provide Aetna Life Insurance Company or one of its affiliated companies ("Aetna"), and any independent claims administrators and consulting health professionals with information relating to treatment provided the patient (including that relating to mental illness or AIDS/ARC/HIV). This information will be used to evaluate claims for benefits. Aetna may provide the employer named above with benefit calculation used in payment of this claim for the purpose of reviewing the experience of the operation or the policy or contract. This authorization is valid for the term of the policy or contract under which a claim has been submitted. I know that I have a right to receive a copy of this authorization, upon request and agree that a photographic copy of this authorization is as valid as the original.

Patient's or Authorized Person's Signature
Date
29. I authorize payment of medical benefits to the physician or supplier of service.
Patient's or Authorized Person's Signature
Date

TO BE COMPLETED BY PHYSICIAN OR SUPPLIER

30. Date of illness (first symptom) or injury (accident) or pregnancy (LMP)
 31. Date first consulted you for this condition
 32. If patient has had similar illness or injury, give dates
 33. If an emergency check here
34. Date patient able to return to work
 35. Date of total disability
from through 		36. Date of partial disability
from through 		37. Name of referring physician (e.g., Public Health Agency)
38. For services related to hospitalization give hospitalization dates
admitted discharged 		39. Name & address of facility where services rendered (if other than home or office)
40. Diagnosis or nature of illness or injury (please indicate primary and secondary)

41. Procedures, Medical Services, Supplies Furnished

Date of Service Place of Service Procedure Code Identify Description of Service Type of Service Charges Days or Units Diagnosis Code Administrative Use Only
Additional service lines may be added as needed.
42. Physician's Name & Address (include zip code)
 43. Telephone Number
 44. Enter the taxpayer identifying number to be used for 1099 reporting purposes.
45. Patient Account Number
 46. Total charge / Amount paid / Balance due
Total charge $
Amount paid $
Balance due $ 		47. Physician's or supplier's signature
48. National Provider Identifier
 49. Date

* Place of Service Codes:

1 - (H) - Inpatient Hospital    2 - (OH) - Outpatient Hospital    3 - (O) - Office Visit

4 - (H) - Patient Home    5 - Day Care Facility (PSY)    6 - Night Care Facility (PSY)

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What the Aetna Student Health Claim Form Is and when it’s used

The Aetna Student Health Claim Form is the insurer-specific document students or providers submit to request reimbursement for medical services covered by an Aetna student health plan. It collects identifying information, policy details, dates and types of services, provider billing codes, and itemized charges. Institutions, students, or healthcare providers use it when a service was paid out-of-pocket, when a provider did not bill Aetna directly, or to supplement electronic claims. Accurate completion helps speed adjudication and reduces the chance of requests for additional documentation from the payer.

Why completing the form correctly matters

Completing the Aetna Student Health Claim Form correctly ensures timely reimbursement, reduces administrative friction, and preserves appeal rights. Accurate entries reduce follow-up requests and support compliance with insurer and federal privacy rules such as HIPAA.

Why completing the form correctly matters

Who typically completes or signs this claim form

Each signer should verify plan ID and attach required supporting documents to prevent delays.

  • Students and dependents submitting out-of-pocket medical expenses for reimbursement or coordination of benefits.
  • University health centers and student services filing on behalf of enrolled students.
  • Healthcare providers and billing offices submitting supplemental documentation or corrected charges to Aetna.

Step-by-step: Completing the Aetna Student Health Claim Form

A clear sequence helps avoid missing data and speeds review. Follow these four practical steps.

  • 01
    Gather documents: Collect ID card, itemized receipts, provider notes.
  • 02
    Complete fields: Fill member details, dates, codes, and amounts precisely.
  • 03
    Attach proofs: Attach receipts, Explanation of Benefits, and any referral letters.
  • 04
    Submit and track: Send to Aetna using the plan’s specified submission method and keep confirmation.

How an Aetna Student Health claim moves through processing

Claims follow a predictable routing: receipt, intake, adjudication, and payment or denial with explanation.

  • Receipt: Claim is received and logged by Aetna.
  • Intake review: Form checked for completeness; missing items flagged.
  • Adjudication: Benefit rules applied; coordination of benefits evaluated.
  • Payment or appeal: Payment issued or denial letter with appeal instructions.

Setting up an efficient digital claim workflow

Use these configuration items when digitizing the claim process to minimize manual steps.

Field mapping Map form fields to EHR or student records for auto-fill.
Required fields Enforce member ID, date of service, provider NPI as required.
Attachment types Allow PDF, JPG, and scanned EOB attachments up to specified size.
Signer authentication Use email or SMS verification for student or provider sign-off.
Notification rules Trigger confirmations to student and university billing upon submission.

Digital submission and platform requirements

Ensure the chosen eSubmission tools meet HIPAA and institutional privacy policies and retain an auditable trail of submissions.

  • File formats: PDF or image files accepted.
  • Authentication: Email or SMS verification recommended.
  • Privacy: HIPAA safeguards required for PHI handling.

Essential information the form must include

Student name: Full legal name
Member ID: Subscriber or policy number
Service dates: MM/DD/YYYY format
Provider NPI: National Provider Identifier
Charges paid: Amount in USD
Supporting docs: Receipts and EOBs

Common errors that delay claims

  • Missing member ID or wrong policy number causes routing delays.
  • Incorrect or absent provider NPI forces manual rework by adjudicators.
  • Vague service descriptions that lack CPT/ICD codes trigger inquiries.
  • Unreadable receipts or missing itemized bills lead to rejections.

Consequences of incomplete or late submissions

Delayed reimbursement: Payments postponed until documentation is complete
Denial risk: Claim can be denied without complete records
Appeal time limits: Missing deadlines can forfeit appeal rights
Privacy violations: Improper PHI handling risks HIPAA penalties
Financial exposure: Out-of-pocket costs may remain unreimbursed
Tax effects: Incorrect reporting may affect tax deductions

Timing: when to submit and what to expect

Submission timelines vary by policy. Confirm plan-specific deadlines but follow best practices to avoid forfeiture of reimbursement.

Prompt submission:

Submit as soon as possible after service; many plans expect prompt filing

Common insurer window:

Many insurers request claims within 90–365 days of service; verify your plan

Appeal periods:

Appeal deadlines vary; review the denial notice for exact dates

EOB linkage:

Attach Explanation of Benefits to speed coordination of benefits

Provider billing:

If provider can bill directly, coordinate to avoid duplicate submissions

Key milestones in claim processing

A typical claim follows a four-stage lifecycle from submission to final resolution.

01

Submission

Form and attachments received by the insurer for intake.

02

Acknowledgement

Insurer issues receipt confirmation or reference number.

03

Adjudication

Claims team applies coverage rules and calculates payable amount.

04

Resolution

Payment issued or denial provided with appeal instructions.

Representative eSignature pricing and capability comparison

Below is a concise vendor comparison focused on starting price and core capabilities relevant to claim form eSubmission and HIPAA workflows.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Realistic scenarios for using the Aetna Student Health Claim Form

These condensed case examples show how institutions and students commonly use the form.

University health center submission

A student pays a campus clinic copay and needs reimbursement

  • Clinic attaches itemized invoice and student Aetna ID
  • The clinic submits the completed claim form with receipts; the student receives an EOB and reimbursement after adjudication within the plan’s stated timeframe.

Out-of-network provider claim

A student sees an out-of-network specialist and pays in full

  • Student collects invoice and proof of payment
  • Student completes the claim form, attaches the itemized bill and proof of payment, and submits for reimbursement or balance adjustment under coordination of benefits rules.

Frequently asked questions about the Aetna Student Health Claim Form

Answers to common questions about completion, submission, and eSignature acceptance for this insurer form.


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