Aetna Precertification Information Request GR-68831

Aetna uses this eight-page form to collect the clinical details behind a precertification case that is already open. You start the request on Availity or by phone; if the response is pended, or you received a reference number by phone, you complete this form and send it with the requested medical records. Aetna then performs a clinical review and makes a coverage determination.

Who completes it

The form directs the patient's attending physician to complete all sections. The person completing it signs and dates Section 11 and names an office contact Aetna can call with questions.

How to fill it in

About this form, How to fill out this form, When you're done

Pages 2 and 3 explain that the form is not used to initiate a request. Start on Availity with the Authorization (Precertification) Add transaction and complete any questionnaire; if the response is pended, complete this form and attach it to the case. The attending physician completes all sections, and missing records can delay review or lead to denial of coverage.

Section 1: Provide the following general information for all requests

Enter the member's name, phone, ID and date of birth, and the reference number for the existing case; without one, the form says not to use it. Add the physician's name, NPI and fax, participating or non-participating status, office phone and the requestor's phone. Type responses if possible, or print clearly.

Section 2: Provide the following general information

Give the facility name, fax and participating status, the assistant or co-surgeon name and TIN if applicable, and the date of the procedure. List the diagnosis codes and the CPT or HCPCS codes, with descriptions, that best describe the services. For drugs or injectables, include the administration codes.

Section 3: Provide the following patient-specific information

Describe the patient's symptoms, your clinical findings, any conservative management tried and its outcome, the anticipated outcome of the proposed treatment, and anything else to consider. State whether you are requesting a hospital admission longer than 24 hours, and if so, give the clinical rationale for inpatient care. This narrative is the core of the clinical review.

Section 4: For Inpatient stays post hip arthroplasty and Total knee

For an inpatient stay after hip or knee arthroplasty, give the expected length of stay and answer whether the patient's BMI is over 40, whether they have COPD or are on oxygen therapy, whether they have end-stage renal disease on regular dialysis, and whether they had a heart attack, stroke or TIA within the past 3 months.

Sections 5 to 7: Dialysis at a non-participating facility, higher benefit level and out-of-network requests

Section 5 asks whether a dialysis member at a non-participating facility is using out-of-network benefits or wants a higher benefit level review. Section 6 asks for the medical reason the member needs a non-participating provider; such coverage is generally not available when a participating provider is. Section 7 records prior visits, services, scheduling and the referring physician.

Section 8: Site-of-service Precertification Requirements

State whether the procedure is inpatient or outpatient and, if outpatient, whether in an outpatient hospital, freestanding ambulatory surgical center or office. For an outpatient hospital, check every factor that applies, such as age under 12, ASA class III or higher, morbid obesity, pregnancy, high-risk cardiac status or bleeding disorders, or equipment unavailable at participating surgical centers.

Section 9: Provide the following documentation for your request

Check off and attach the current history and physical, office notes for the condition, notes supporting hospitalization, a description of the proposed treatment, and lab, pathology and x-ray reports if applicable. DME requests add product descriptions and usage instructions; potentially experimental procedures add FDA or medical society positions and published literature; cosmetic procedures may need photographs.

Section 10: Read this important information, and Section 11: Sign the form

Section 10 warns that knowingly filing a request with materially false or concealed information to deceive an insurer is a fraudulent insurance act carrying criminal and civil penalties. In Section 11, the person completing the form signs and dates it and gives the name and phone of office personnel to call with questions.

Common mistakes

Using the form to initiate precertification; without a reference number, Aetna says to submit on Availity or call the Precertification Department first.
Leaving sections blank or omitting requested medical records, which Aetna says may delay the review or result in denial of coverage.
Handwriting answers that are hard to read; typed responses are preferred, and handwritten ones must be printed clearly.
Sending claims or other non-clinical paperwork to the FaxHub line, which is for clinical information supporting the medical necessity review only.
Mailing the form when fax or electronic submission is available; mail adds to the review response time.
Skipping Aetna's Clinical Policy Bulletins for non-Medicare members, which Aetna encourages you to review before completing the form.

Submitting and payment

How to submit it: Attach it, with the requested medical records, to the existing case on Availity using the reference number, or send it by confidential fax to Aetna's FaxHub line for clinical information. Mail is accepted only when neither fax nor electronic submission is available, and it adds to review time.
Who pays: Aetna's review decides coverage of the service, using CMS national and local coverage determinations for Medicare Advantage members when available and its Clinical Policy Bulletins otherwise.

Good to know

It applies to Aetna plans, including Medicare Advantage, Innovation Health plans, and plans offered with Allina Health (Allina Health | Aetna) and Banner Health (Banner | Aetna).
Without a reference number, do not use this form: initiate precertification on Availity with the Authorization (Precertification) Add transaction, or by phone, then answer any questionnaire.
Related forms include procedure-specific precertification forms for hip and knee arthroplasty, sinus surgery and spinal surgery, and state standard forms for Arizona, Texas, New Mexico, Nebraska and Massachusetts.
The current version is GR-68831 (11-25), with form code PCFX printed on the first pages. Typed responses are preferred.

Get the official form

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

Precertification Information Request Form

Official page PDF

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.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Can I start an Aetna precertification with this form?

No. Aetna says not to use the Precertification Information Request Form to initiate a request. Submit the request on Availity or call the Precertification Department first. If Availity returns a pended response, or you started by phone and have a reference number, complete this form and attach it to the case.

Where do I find the reference number for the form?

The reference number comes from the precertification you already started. Aetna puts the administrative reference number on the electronic precertification response, and a phone request also produces one. Enter it in Section 1 and on each later page; the form says that if you have no reference number, you should not use it.

Does the Aetna precertification form work for Medicare Advantage members?

Yes. The form can be used with all Aetna health plans, including Aetna's Medicare Advantage plans, and with plans for which Aetna provides management services. For Medicare Advantage members, Aetna applies CMS national and local coverage determinations when available, falling back to its Clinical Policy Bulletins.

What records should I send with the Aetna precertification form?

Section 9 lists the current history and physical, office notes on the condition being treated, notes supporting any hospitalization, a description of the proposed treatment, and lab, pathology and x-ray reports. DME requests add product descriptions and usage instructions; experimental procedures need FDA or society positions and published literature; cosmetic procedures may need photographs.