Provider forms and resources

• Medical Prior Authorization form (PDF)
• Part D Coverage Determination form (PDF)
• Hospice Medicare Part D exception form (PDF)
• Electronic Visit Verification Authorization Form (PDF)
• 2025 Auth and Appeals Metrics (PDF)

ECHO Health Inc Enrollment

• Part D Coverage Redetermination Request form (PDF)
• Non-PAR Provider Appeal Form (PDF)
• PAR Provider Dispute Form (PDF)
• Waiver of Liability (WOL) form (PDF)

• Orthodontic Evaluation HLD Instructions & NJ-Mod3 Form (PDF)
• ADA Caries Risk Assessment Form for PCD use (Age 0-6) (PDF)
• ADA Caries Risk Assessment Form for PCD use (Age 6yrs and older) (PDF)
• AAP Caries Risk Assessment Form for PCP use (PDF)

• 2026 Prescription Drug Search tool
• 2026 Pharmacy locator search tool
• Join our network

Contact Us

• Providers who are interested in joining the Aetna Medicare FIDE (HMO D-SNP) network for Community Based Palliative Care should reach out the Aetna Medicare FIDE (HMO D-SNP) Network Team at AetnaDualsContracting@AETNA.com

• In your email, please include a letter of intent with the information outlined below.

  • Group Name

  • Group NPI

  • Group TIN

  • Service address (including county)

  • Provider Name(s)

  • Individual NPI

  • Specialty

• The contract manager that handles the county in which you are located will contact you with the documents required to initiate the contracting/credentialing process.

• Contact us
• Fraud, waste and abuse
• State of NJ's Medicaid Fraud Division Reporting Form
• Complaints and appeals
• Coverage determination form
• Redetermination request form
• Special Needs Survey (PDF)
• Consent to Sterilization Form (PDF)
• CBPC Comprehensive Medical Assessment Tool (CMAT) (PDF)
• CBPC Program Eligibility Screening Tool (PDF)