Aetna Provider Information Change Form

Posted on

In this guide, we are going to discuss Aetna Provider information change form. If you come to this page to find out some information about that, make sure you will read this article until the end.

Aetna Provider Information Change Form

You have to complete all applicable information. Remember that incomplete submissions may be returned unprocessed. Not for the new providers or contractual or credentialing changes. If you want to submit your licensed and/or unlicensed provider roster, please complete their Data Long form and OIG form. Download form here

  1. Indicate changes being submitted

You have to check all that apply, please include the effective date for each item checked.

  • Firstly, you have to submit an effective date for group information.
  • Then, you have to submit an effective date for billing information.
  • After that, you have to submit an effective date for the provider name.
  • Next, you have to submit an effective date for practice status.
  • Lastly, you have to submit an effective date for termination.

Please complete the applicable sections to update your information. If changing tax information, you are needed to submit an updated w9 with this form.

  1. Group Information
  • Firstly, you have to enter your group name.
  • After that, enter group NPI, Medicaid ID (if applicable), and TAX ID.
  • Then, enter your group Email Address.
  • Do not forget to enter the street, city, state and Zip.
  • Of course, you have to enter your phone and Fax.
  • Next, you have to enter an individual Provider (or Alternate) Email Address.
  • Please enter Individual Provider Ethnicity, Individual Provider Gender and Individual Provider Language.

If applicable, you have to attach a separate list on the letterhead with the names and NPI numbers of all of the providers in the group for whom the address change is applicable.

  1. Address Information

Enter new or additional addresses below:

  • Firstly, you have to select address type; Primary, Secondary, Billing and Mailing.
  • Then, enter address line 1.
  • After that, enter address line 2.
  • Also, you have to enter your City, State and Zip.
  • Do not forget to enter the phone and Fax.
  • Submit Office hours.
  • Inform the languages spoken by Provider or Office Staff.

Enter old addresses to be terminated below:

  • Firstly, you have to select address type; Primary, Secondary, Billing and Mailing.
  • Then, enter address line 1.
  • After that, enter address line 2.
  • Also, you have to enter your City, State and Zip.
  • Do not forget to enter the phone and Fax.
  • Submit Office hours.
  • Inform the languages spoken by Provider or Office Staff.

Group Name

  • Firstly, you have to select address type; Primary, Secondary, Billing and Mailing.
  • Then, enter address line 1.
  • After that, enter address line 2.
  • Also, you have to enter your City, State and Zip.
  • Do not forget to enter the phone and Fax.
  • Submit Office hours.
  • Inform the languages spoken by Provider or Office Staff.

Group Tax ID

  • Firstly, you have to select address type; Primary, Secondary, Billing and Mailing.
  • Then, enter address line 1.
  • After that, enter address line 2.
  • Also, you have to enter your City, State and Zip.
  • Do not forget to enter the phone and Fax.
  • Submit Office hours.
  • Inform the languages spoken by Provider or Office Staff.
  1. Individual Provider Status

This may be impacted by contract terms, and follow-up may be needed.

You have to determine Practitioner availability status:

  • Accepting the new patients
  • Accepting existing patients only
  • Closed (not accepting the new patients and not accepting existing patients)
  • Or other (please specify)

Do you offer telemedicine or telehealth such as video visits? For this case, you only need to select Yes or No.

  1. Termination

Effective dates can be impacted by contract terms and follow-up can be needed. Please attach a separate sheet on the letterhead if several providers are terminating from the group.

Group termination

  • Enter NPI# for Group location(s) terminating

Individual Provider termination

  • Enter NPI# for Individual provider(s) terminating from Group

Also, reason for termination, please check only onebox:

  • Resigned
  • Retired
  • Deceased
  • Moved out-of-state
  • Practice closed
  • Provider sanctioned
  • Provider transferred to (a new group name)
  • Other (please specify)
  1. Contact Person Submitting Information
  • At the first step, you have to enter your name.
  • After that, you have to enter your title.
  • Then, you have to submit your phone number.
  • Next, you have to enter your Fax
  • Do not forget to submit your email.
  • Also, submit date of submission.

Warning: You have to submit your form to Aetna Better Health of Louisiana Provider Relations via email at LAProvider@aetna.com or fax at 1-860-607-7658. Any questions or concerns, you are able to contact Aetna Better Health of Louisiana Provider Relations by calling 1-855-242-0802 and following the prompts.

Practitioner Information Change

Please ensure your contact information is current with them. If you want to make changes for your information, then you have to fill out the form on page 2. You are able to fill out one form per provider in your practice. Simply, you will be able to changes your:

  • Name
  • Physical and mailing addresses
  • TIN
  • NPI
  • Social security number
  • Specialty type
  • Board certification
  • License
  • Hospital affiliations

Also, you need to attach important information with your change request, like a W-9 or your licensure. Please remember to complete the whole form. If you leave anything blank, it will delay your request. After completion, fax it to 1-860-754-5435. Or you are able to email it to ABHProviderRelationsMailbox@AETNA.com. For those who have more than 10 providers that need changes, use their provider roster update spreadsheet instead. Send the updated spreadsheet to ABHProviderRelationsMailbox@AETNA.com.

Your information is very crucial. And your information helps us:

  • Send payment to you with no delay or error.
  • Create updates in a timely manner.
  • Send crucial information about new products and initiatives.
  • Meet state and NCQA requirements.

Leave a Reply

Your email address will not be published.