HiddenHidden Claimant ID* HiddenHidden Last Name* PROOF OF GREATER COVERED CARE SUBMISSION Goidel et al. v Aetna Life Insurance Company U.S. District Court, Southern District of New YorkCase No. 1:21-cv-07619(VSB) If Aetna has not already paid for artificial insemination procedures (intracervical insemination (“ICI”) or intrauterine insemination (“IUI”)) for which you submitted precertification requests or claims, or for which you submitted a Claim Form if you are a Category C Class Member, and those services would have been covered by your healthcare plan if not for the Definition of Infertility, YOU WILL AUTOMATICALLY RECEIVE $2,300 If you incurred expenses in an amount greater than $2,300 for artificial insemination procedures that would have been covered by your healthcare plan but for Defendant’s Definition of Infertility, you may be entitled to additional compensation and should complete this Proof of Greater Covered Care Submission. Fully completed and signed Proof of Greater Covered Care Submissions must be received by the Settlement Administrator by Bar Date. Proof of Greater Covered Care Submissions will be evaluated by the Defendant, who will have sole discretion in determining what, if any, additional Dollars for Benefits Payment compensation you may be entitled to. Documentation that you provide as supporting evidence will not be returned. Please retain copies of your documents for your own records. You will be notified by mail and/or email if anything additional is needed for your Proof of Greater Covered Care Submission. Please make sure the Settlement Administrator has your current mail and email addresses. Use any of the following options to submit your form and documentation before Bar Date:STEP 1: CLASS MEMBER INFORMATIONClass Member Name* First Middle Last Aetna Member Number (W Number):*Class Member Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Class Member Email Address:* Class Member Telephone*Class Member Telephone Type**** Select a Choice ***MobileHomeSTEP 2: FERTILITY TREATMENT INFORMATIONPlease provide the information in the following chart for each cycle of artificial insemination that you underwent between September 1, 2017, and June 1, 2024 that, in total, would have resulted in an aggregate reimbursement exceeding $2,300 by your Aetna healthcare plan. Supporting evidence for each procedure included is required and must be submitted with this form. Add additional procedures on a separate piece of paper if necessary. Descriptions of the applicable artificial insemination Codes covered by this settlement are as follows: S4035-Artificial Insemination Menotropin Stimulated intrauterine insemination 58321-Artificial Insemination; Intra-CervicalIn this procedure, the provider inserts prepared live sperm into the cervical canal. 58322-Artificial Insemination; Intra-UterineIn this procedure, the provider inserts prepared live sperm into the uterus through the cervical canal. Cycles of in-vitro insemination (“IVF”) will not qualify you for Class Membership and should not be submitted. FIRST CYCLE BETWEEN SEPTEMBER 1, 2017, AND JUNE 1, 2024:Date of Service (mm/dd/yyyy):* CPT Code- Check the box(s) that apply (see page 2):* S4035 58321 58322 Provider TIN/PIN:* Provider NPI:* Provider Name:* Provider Address:* Street Address City State Zip Code Provider Phone:*Amount Paid*SECOND CYCLE BETWEEN SEPTEMBER 1, 2017, AND JUNE 1, 2024:Date of Service (mm/dd/yyyy):* CPT Code- Check the box(s) that apply (see page 2):* S4035 58321 58322 Provider TIN/PIN:* Provider NPI:* Provider Name:* Provider Address:* Street Address City State Zip Code Provider Phone:*Amount Paid*THIRD CYCLE BETWEEN SEPTEMBER 1, 2017, AND JUNE 1, 2024:Date of Service (mm/dd/yyyy):* CPT Code- Check the box(s) that apply (see page 2):* S4035 58321 58322 Provider TIN/PIN:* Provider NPI:* Provider Name:* Provider Address:* Street Address City State Zip Code Provider Phone:*Amount Paid*STEP 4: DOCUMENTATION Provide the required supporting evidence related to the artificial insemination procedure(s) described in STEP 3. Examples of acceptable forms for supporting evidence might include a bill from your provider (with proof of payment, i.e. cancelled check or credit card statement). Evidence provided must, at a minimum, confirm (1) you received a service, (2) what service you received, (3) that you were billed for a service, and (4) you paid for the service received. Supporting Documentation* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB. STEP 5: CERTIFICATION AND SIGNATUREFull Name* Signature* I certify under penalty of perjury that the information included in this Proof of Greater Coverage Submission and the accompanying supporting evidence of the procedures completed are true and correct to the best of my knowledge. ClaimFormNoUnique IDPhoneThis field is for validation purposes and should be left unchanged.
