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The form explains completion requirements for the requesting physician or provider and warns that incomplete submissions and missing medical records may delay review or lead to denial. It provides submission channels including Availity Essentials, confidential fax, and EDI or phone, then describes the clinical review process and coverage determination using Medicare guidance and Aetna supplemental policies. Includes member, ordering/referring provider, requesting provider, facility/service provider, procedure type, diagnosis codes, CPT/HCPCS, service dates, and visit quantity fields.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/illinois-fide-prior-authorization-request-form-aetna-medicare-fide-hmo-d-snp/288447/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/illinois-fide-prior-authorization-request-form-aetna-medicare-fide-hmo-d-snp/288447.png","ImageObject",442,249,{"name":88,"@type":89},"Angel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who must complete this prior authorization request form?","Question",{"text":108,"@type":109},"The requesting physician and/or provider must complete all sections of the form.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What happens if the form or medical records are incomplete?",{"text":113,"@type":109},"Failure to complete the form and submit all related medical records may result in delayed review or denial of coverage.",{"name":115,"@type":106,"acceptedAnswer":116},"How are coverage decisions made after the request is received?",{"text":117,"@type":109},"A clinical review is performed using documentation, followed by a coverage determination based on nationally recognized clinical guidelines and Medicare policies.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288447,1790146509,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":73,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},687207412472,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Aetna® Medicare FIDE (HMO D-SNP) PO Box 818051  \nCleveland OH 44181-8051  \nPhone: 1-866-600-2139 (TTY: 711)  \nFax: 1-855-320-8445  \n[Health plan website: AetnaMedicare.com/ILDSNP](Health plan website: AetnaMedicare.com/ILDSNP)  \nPrior authorization request form  \nAbout this form: Failure to complete this form and submit all medical records related to the request may result in the delay of review or denial of coverage.  \nHow to fill out this form: Use this form only for the Aetna Medicare FIDE (HMO D-SNP) health plan. The requesting physician and/or provider must complete all sections of this form.  \nWhen you’redone  \nOnce you’ve filled out the form, submit it and all medical documentation to support your request to our Prior Authorization Department via:  \n• Our free provider portal, Availity Essentials (our preference). You can use it in place of this form to start, update, upload clinical and check the status of a prior authorization [Please visit](Please visit Availity.com/aetnaproviders to register)[ Availity.com/aetnaproviders](Please visit Availity.com/aetnaproviders to register)[ ](Please visit Availity.com/aetnaproviders to register)[to register](Please visit Availity.com/aetnaproviders to register).  \n• Confidential fax to \u003C1-855-320-8445>.  \n• Electronic Data Interchange (EDI) or by calling us at \u003C1-866-600-2139 (TTY: 711)> to expedite requests.  \nWhat happens next?  \nWe’ll perform a clinical review once we receive the request with documentation. Then we’ll make a coverage determination and let you know a decision.  \nHow we make coverage determinations  \nTo support coverage decisions, we use nationally recognized clinical guidelines and resources, such as:  \n• Medicare National Coverage Determinations (NCD)  \n• Medicare Local Coverage Determinations (LCD)  \n• Medicare Benefit Policy Manual  \n• Other applicable Medicare requirements  \n• Aetna supplemental policies  \nYou can find Aetna supplemental policies on our Health Plan website,  \n[AetnaMedicare.com/ILDSNP](AetnaMedicare.com/ILDSNP)  \n\u003CH9771_5592273_2026_C>  \nAetna® Medicare FIDE (HMO D-SNP) PO Box 818051  \nCleveland OH 44181-8051  \nPhone: 1-866-600-2139 (TTY: 711)  \nFax: 1-855-320-8445  \nPRIOR AUTHORIZATION FORM forAetna® Medicare FIDE (HMO D-SNP) Date of Request:    \nMEMBER INFORMATION  \nName:   ID Number    \nDate of Birth:    \nGender (circle one): F M  \nMember’s Primary Care Physician:    \n\n| Ordering/Referring Provider |\n| --- |\n| Name: |\n| Address: |\n| Telephone: |\n| Fax: |\n| NPI Number: |\n| Contact Person: |\n\n\n| **Requesting Provider-Who is requesting/submitting the service authorization request toAetna Medicare FIDE (HMO D-SNP) |\n| --- |\n| Name: |\n| Address: |\n| Telephone: |\n| Fax: |\n| NPI Number: |\n| Contact Person: |\n\n\n| Place of Service, Facility Name or Servicing Provider |\n| --- |\n| Name: |\n| Address: |\n| Telephone: |\n| Fax: |\n| NPI Number: |\n| Contact Person: |\n\n\n| Type of Procedure (circle one): Inpatient Outpatient DME Medicare Part B Drug |\n| --- |\n| Diagnosis/ICD-10 Code(s): |\n| Procedure /Item Requested (CPT/HCPCS Code(s)): |\n|  |\n| Date (or Span) of Appointment or Service: Start Date  End Date  |\n| Number of Visits/Qty Required:   |\n\n\u003CH9771_5592273_2026_C>","cbCaiet0quX1kmTO","https://ap.wps.com/l/cbCaiet0quX1kmTO","pdf",144843,"English","# Prior authorization request form overview\n## How to fill out the form\n## Submission methods and next steps\n## How coverage determinations are made\n# Form fields\n## Member information\n## Ordering/referring provider\n## Requesting provider\n## Place of service / facility / servicing provider\n## Procedure, diagnosis, and service details","[{\"question\":\"Who must complete this prior authorization request form?\",\"answer\":\"The requesting physician and/or provider must complete all sections of the form.\"},{\"question\":\"What happens if the form or medical records are incomplete?\",\"answer\":\"Failure to complete the form and submit all related medical records may result in delayed review or denial of coverage.\"},{\"question\":\"How are coverage decisions made after the request is received?\",\"answer\":\"A clinical review is performed using documentation, followed by a coverage determination based on nationally recognized clinical guidelines and Medicare policies.\"}]","Illinois FIDE Prior Authorization Request Form - Aetna Medicare FIDE (HMO D-SNP) | PDF",1789633493]