Out Of Network Vision Services Claim Form - 2013 printable pdf download

DeltaVision®

OUT-OF-NETWORK VISION CARE CLAIM FORM

DeltaVision, in association with the EyeMed Vision Care Access and Select networks, offers vision care plans that

give enrollees access to a national network of both independent providers and leading optical retailers.

Most

DeltaVision plans allow members to visit an in-network or non-network vision provider.

You only need to complete this form if you are visiting a provider that is not a participating

provider in the EyeMed Access or Select network. Not all DeltaVision 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.

1. When visiting a non-network provider, you are responsible for payment of vision care services and/or materials

at the time of service. DeltaVision will reimburse you for authorized services according to your plan design.

Please consult your plan design for the listing of qualified services and their reimbursement amounts.

2. Please complete all sections of this form to ensure proper benefit allocation. Plan Information can be found on

your DeltaVision ID card or by contacting your Human Resources Department.

3. Only itemized paid receipts that indicate the services provided and the amount charged for each service will be

accepted. The services must be paid in full in order to received 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 is US dollars, please identify the currency in which the receipt was paid.

4. If you are submitting for a secondary insurance benefit, please include a copy of your Explanation of Benefits.

5. Sign the claim form. If the patient is a minor, the parent or legal guardian is required to sign the claim form.

Mail the claim form and itemized paid receipts to:

DeltaVision Claims Processing

c/o EyeMed Vision Care

P.O. Box 8504

Mason, OH 45040-7111

Please allow at least 14 calendar days to process your claims once received by EyeMed. A check and/or

explanation of benefits will be mailed within seven (7) calendar days of the date your claim is processed.

If you submit incomplete documentation, a delay in reimbursement may occur. Without prior authorization for

services, there is a risk that you may not receive the entire benefit you are requesting reimbursement for.

Inquiries regarding your submitted claim should be made to EyeMed toll-free at 1-866-723-0513. The Customer

Care Center is available Monday through Saturday 7:00 a.m. to 10:00 p.m. CST and Sunday from 10:00 a.m. to

7:00 p.m. CST. After hours, please leave a voice mail request, including patient name, Member ID, the requested

services and your daytime telephone number.

Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer, submits an

application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

* DeltaVision is provided by ProTec Insurance Company, a wholly-owned subsidiary of Delta Dental of Illinois, in

association with EyeMed Vision Care networks.

Out Of Network Vision Services Claim Form - 2013