RESOURCE CENTER

Client Service Forms
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AFA GRX census template
To be used for groups with 15+ enrolled and they wish to receive a firm AFA quote with underwriting based on Rx lookup. This census MUST be used.
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2017 AFA IMQ Questionnaire (short form)
Required for any groups with less than 20 enrolling or a virgin groups. If UW has more questions, a long form may be requested. Illustrative quote can be obtained, but rates will not be firm until IMQ is received.
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New PA business addendum form (TAE - employee count)
This information is needed in order to comply with federal law. Aetna needs to know the total # of all employees the employer had in 2016, even if you were not covered by Aetna. This is required for PA AFA quoting.
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AFA Sold Case Paperless Process
The new process is as close to paperless as they can get. Once we receive the CIR form, Aetna prepopulates all other forms, communicates with both broker and B&B, and only requires an Eco-Signature.
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Electronic enrollment, Billing/payment, and Access agreement (form NB411)
required for all groups. This form authorizes the setup of e-enrollment and e-billing, and it must be filled out to authorize use of eLists for electronic eligibility.
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2015 Aetna Funding Advantage - New Customer Checklist
This checklist reviews all the documents you will need to submit in order to apply for Aetna Funding Advantage. The process can take longer than a fully insured installation, so begin working with your account manager as soon as possible.
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Census for Member Level Rating (100+ eligibles)
Aetna branded sample census for Member level rating. Effective immediately, for groups under 200 lives, Aetna will require member level census. Employer’s contribution strategy is needed by Aetna as well.
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2015 Employee Application (for PA group coverage 1-50 eligible)
Employee enrollment form for PA situs groups groups with 1-50 eligible employees. This app must be used for groups 2015 effective and forward, old apps will not be accepted.
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2015 Employee Application (for PA group coverage 51-100 eligible)
Employee enrollment form for PA situs groups groups with 51-100 eligible employees. This app must be used for groups 2015 effective and forward, old apps will not be accepted.
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Employer Verification Form
Required form in order for Aetna to determine what mandatory state laws are applicable to your client. Typically required at initial installation or at renewal.
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2014 Employee Enrollment/Change Form (51-100 Eligible NJ Employees)
Employee enrollment form for NJ situs groups groups with 51-100 eligible employees. This app must be used for groups 2014 effective and forward, old apps will not be accepted.
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2014 Employee Enrollment/Change Form (1-50 Eligible NJ Employees)
Employee enrollment form for NJ situs groups groups with 1-50 eligible employees. This app must be used for groups 2014 effective and forward, old apps will not be accepted.
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2014 Employee Enrollment/Change Form (51-100 Eligible PA Employees)
Employee enrollment form for PA situs groups groups with 51-100 eligible employees. This app must be used for groups 2014 effective and forward, old apps will not be accepted.
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2014 Employee Enrollment/Change Form (2-50 Eligible PA Employees)
Employee enrollment form for PA situs groups groups with 2-50 eligible employees. This app must be used for groups 2014 effective and forward, old apps will not be accepted.
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