Out-Of-Network Claim Form printable pdf download

Out-Of-Network Claim Form

Most EyeMed Vision Care plans allow members the choice to visit an in-network or out-of-network vision care provider. You only

need to complete this form if you are visiting a provider that is not a participating provider on the EyeMed network. Not all plans

have out-of-network benefits, so please consult your member benefits information to ensure coverage of services and/or materials

from non-participating providers.

If you choose an out-of-network provider, please complete the following steps prior to submitting the claim form to EyeMed. Any

missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to

EyeMed within 1 year from the original date of service at the out-of-network provider’s office.

1. When visiting an out-of-network provider, you are responsible for payment of services and/or materials at the time of service.

EyeMed will reimburse you for authorized services according to your plan design.

2. Please complete all sections of this form to ensure proper benefit allocation. Plan information may be found on your benefit ID

Card, or via your human resources department.

3. EyeMed will only accept itemized paid receipts that indicate the services provided and the amount charged for each service.

The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider’s letterhead. Attach

itemized paid receipts from your provider to the claim form. If the paid receipt is not in US dollars, please identify the currency in

which the receipt was paid.

4. Please include a copy of your Explanation of Benefits if submitting for a Secondary Insurance Benefit.

If the reimbursement is to be sent to someone other than the primary subscriber, a copy of a cancelled check or credit card receipt

(in addition to the paid itemized receipt) must be included. A copy of a receipt showing payment in cash is also acceptable.

If applicable, check the box for payment to be addressed to the patient in lieu of the subscriber.

By signing below, you are representing that you are legally divorced or separated and the patient is entitled to the reimbursement. If it is later determined that the

patient was not entitled to the reimbursement, you agree to refund EyeMed in full.

6. Sign the claim form below.

Date of Service: ___/___/_____

Patient Information:

Last Name: _________________

First Name: ______________

MI: ______________

Street Address: _________________________________________________________________

City: ______________________

State: _________________

Zip: ______________

Phone: _____________________

Birth Date: ________________

Plan Information:

Subscriber Name

Last:________________________

First: ________________

MI: ______________

Plan Name: ___________________________________________________________________

Subscriber ID: ________________

Request For Reimbursement –Please Enter Amount Charged. Remember to include itemized paid receipts:

Exam:

Frames:

Lenses:

Contact Lenses – (includes fit and follow-up, please submit

$_______

$______

$________

$__________

all contact related charges at the same time)

If lenses were purchased, please circle type:

Single

Bifocal

Trifocal

Progressive

I hereby understand that without prior authorization from EyeMed Vision Care LLC for services rendered, I may be denied reimbursement for submitted vision care

services for which I am not eligible. I hereby authorize any insurance company, organization employer, ophthalmologist, optometrist, and optician to release any

information with respect to this claim. I certify that the information furnished by me in support of this claim is true and correct.

Member/Guardian/Patient Signature (not a minor) ________________________________ Date: _________

To Fax: 866-293-7373

To Email Form and Receipts:

To Mail:

EyeMed Vision Care Attn: OON Claims

P.O. Box 8504

Mason, OH 45040-7111