Provider Request Form

Use this form to ask about enrollment, claims and more. Need to check patient eligibility and benefits, submit and check status on prior authorizations or grievances and appeals? Use Availity. You can also call Provider Relations and/or email contracting for new contract requests or credentialing questions.

Inquiry information

*The reason for your inquiry is

*Choose the reason you’re contacting us

*State

*Choose your state

Requester information (at provider’s office)

*NAME

*Type your first and last name

*TITLE

*Type your title

*EMAIL

*Type your email

*PHONE (10 DIGITS)

*Use 10 digits and no spaces or dashes Use 10 digits and no spaces or dashes

Provider information

Individual Group or facility

*First Name

*Type the provider’s first name

*LAST NAME

*Type the provider’s last name

*TAX ID

*Type the provider's TAX ID Use 9 digits with no spaces or dashes

*NPI

*Type the provider’s NPI Use 10 digits with no spaces or dashes

COMMENTS

Complete all form fields before attaching files.

You may attach 5 image, text or PDF files up to 35 MB per submission.
(must be one of the following file types: .xls, .xlsx, .pdf, .tif, .jpg, .csv, .doc, .docx, .zip)

Choose the files to attach.

Choose file

Aetna Better Health complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.