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The form explains that completion is voluntary, provides instructions to contact Member Services or submit a written request, and collects primary insured/member details from the ID card. It also requests information about the requesting person, relationship, appeal type (pre-service or post-service), relevant claim/reference numbers, service dates, an explanation of the request, signature, and submission materials such as bills and correspondence, including mailing and fax options.",{"@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/member-complaint-and-appeal-form-crtm-gr-68192-1/281315/",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/member-complaint-and-appeal-form-crtm-gr-68192-1/281315.png","ImageObject",442,249,{"name":88,"@type":89},"Rhys","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-03","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":45},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Is completing this form required to request a review?","Question",{"text":108,"@type":109},"Completion of the form is voluntary. 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To obtain a review, you or your authorized representative may also call our Member Services Department using the telephone number displayed on the member ID card or submit a request in writing to the address listed at the end of your Explanation of Benefits (EOB) or other correspondence received from Aetna.  \nPlease provide the following information for the primary Insured/Member.(This information may be found on the front of your ID card.)  \n\n| Today’s Date | Member’s ID Number | Plan Type\u003Cbr> Medical  Dental | Member’s Group Number (Optional) |\n| --- | --- | --- | --- |\n\n\n| Member’s First Name | Member’s Last Name | Member’s Birthdate (MM/DD/YYYY) |\n| --- | --- | --- |\n| Member’s E-mail Address |  |  |\n\nPlease provide the following information for the person you are submitting the request for.  \n\n| First Name | Last Name | Birthdate (MM/DD/YYYY) |\n| --- | --- | --- |\n| Relationship to person requesting the appeal:\u003Cbr> Self  Spouse  Child  Other   Note: If your selection is spouse, child (18 years of age or older) or other, please submit a completed an Authorized\u003Cbr>Representative Form with your request. The form can be found [on](on Aetna.com)[ ](on Aetna.com)[Aetna.com](on Aetna.com). |  |  |\n| Please advise if the appeal is related to:\u003Cbr> Pre-Service  Post Service |  |  |\n\nTo help Aetna review and respond to your request, please provide the following information.  \n(This information may be found on correspondence from Aetna.)  \n\n| Claim ID Number\u003Cbr>(If Post Service selected above.) | Reference Number\u003Cbr>(If Pre-Service selected above.) | Service Date\u003Cbr>(If Post Service insert date of services, if Pre-Service insert date of denial.) |\n| --- | --- | --- |\n| Explanation of Your Request (Please use additional pages if necessary.) |  |  |\n| Member’s Signature |  |  |\n\nNote: When submitting this form with your request please include: - Bills and/or correspondence for these services.  \n- Any other helpful information.  \nYou may mail your request to: Aetna  \nPO Box 14463  \nLexington, KY 40512  \nOr use our National Fax Number:  859-425-3379CRTM  \nGR-68192 (8-25) K 1 R-POD  \nTTY: 711  \n\n| English | To access language services at no cost to you, call the number on your ID card. |\n| --- | --- |\n| Amharic | የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ፡፡ |\n| Arabic | ٔ\u003Cbr>.ﻟﻠﺤﺼﻮل ﻋﻠﯽ اﻟﺤخ ﺪﻣﺎٮت اﻟﻠﻌخ ﻮتيﻪت دوںخ اى تت ﻜﻠفخ ﻪت ، اﻟﺮﺣب ﺎء اﻟﺼﺎل ﻋﻠﯽ اﻟﺮفت ﻢ اﻟﻤﻮﺣب ﻮد ﻋﻠﯽ ىب ﻄﺎفت ﻪت اﺳش تت ﺮاﻛكك\u003Cbr>ي |\n| Armenian | Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար զանգահարեք ձերբժշկական ապահովագրության քարտի վրա նշված հէրախոսահամարով հէրախոսահամարով |\n| Carolinian\u003Cbr>(Kapasal Falawasch) | Ngir mëna am sarwis lakk yi te doo fay, woo nimero bi am ci sa kàrt. |\n| Chamorro | Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion. |\n| Chinese Traditional | 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼 |\n| Cushitic-Oromo | Tajaajiiloota afaanii gatii bilisaa ati argaachuuf, lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraajiruun bilbili. |\n| French | Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro indiqué sur votre carted'assurance santé . |\n| French Creole (Haitian) | Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon asirans sante ou. |\n| German | Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an. |\n| Greek | Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε τον αριθμό στην κάρτα ασφάλισής σας . |\n| Gujarati | તમારે કોઇ પણ તના ખચર્ ના ભાષા સેવાઓ મેળવવા માટે, તમારા આઇ કાડપર રહેલ નંબર પર કૉલ કરવો . |\n| Hindi | बना कसी कमत के भाषा सेवाआ का उपयोग करने के लए, अपने आइड काडर् पर दए नंबर पर कॉल कर। |\n| Hmong | Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID. |\n| Italian | Per accedere ai servizi linguistici senza alcun costo per lei, ch","cbCaiiKZE9r0lFem","https://ap.wps.com/l/cbCaiiKZE9r0lFem","pdf",905974,"English","# Member information\n## Today’s date, member ID, plan type and group number\n# Requesting person details\n## Relationship and appeal type\n# Appeal information for review\n## Claim/reference numbers, service date, request explanation, signature\n# Submission instructions\n## Mailing address, fax number, required attachments\n# Language services notice","[{\"question\":\"Is completing this form required to request a review?\",\"answer\":\"Completion of the form is voluntary. To obtain a review, the member or an authorized representative can also call Member Services or submit a request in writing.\"},{\"question\":\"What information is needed about the primary insured/member?\",\"answer\":\"The form requests today’s date, member ID number, plan type (medical/dental), optional group number, member first and last name, birthdate, and email address.\"},{\"question\":\"How does the form handle pre-service versus post-service appeals?\",\"answer\":\"It asks whether the appeal is related to pre-service or post service, and then collects either a reference number (pre-service) or a claim ID number plus a service/denial date (post-service).\"}]","Member Complaint and Appeal Form - CRTM GR-68192 1 | PDF",1789565463]