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Aetna GR-69140: Provider Complaint and Appeal Request

Aetna requires practitioners and providers to use form GR-69140 when appealing or complaining about a claim, payment or coverage decision, whether clinical or administrative. A clinician meets it after a denial or reconsideration result they want reviewed. The office sends it with supporting records to the address on the Explanation of Benefits or Aetna's correspondence, and Aetna sends its resolution to the listed contact.

Who completes it

The treating practitioner, provider or office staff completes the one-page form: member details from the ID card, provider TIN and NPI, claim and authorization numbers, denial dates, the disputed CPT or HCPCS service and an explanation.

Submitting and payment

How to submit it
Mail it with supporting documents to the address on the EOB or other Aetna correspondence, or send it to Aetna's national provider appeal fax line printed on the form.

Good to know

  • One form can appeal multiple dates of service for the same member; list each claim ID and service date.
  • Supporting documents may include medical records, office notes, discharge summaries, lab records and member history.
  • If you act for the member with their signed authorization, or appeal a preauthorization denial before services are given, use the member complaint and appeal form instead.
  • Aetna has a separate Medicare Contracted Practitioner/Provider Complaint and Appeal request, and California providers have a Provider Dispute Resolution request.

Get the official form

Download the current version from the source each time; forms change without notice.

Practitioner and Provider Complaint and Appeal Request

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Is the Aetna GR-69140 form required for provider appeals?

Yes. The form states that completing it is mandatory to obtain a review. Submit it with information supporting the appeal, such as medical records, office notes, discharge summaries, lab records or member history, to the address listed on the Explanation of Benefits or other correspondence from Aetna.

Can I use GR-69140 to appeal a denied precertification?

Not when the services have not been rendered yet. The form directs providers appealing a preauthorization denial for services still to come, or acting on the member's behalf with a signed authorization, to use the member complaint and appeal form. GR-69140 is for the provider's own complaints and appeals.