Vision Services Claim Form - 2016 printable pdf download

Claim Form Instructions

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 in the EyeMed network. Not all plans have out-of-network benefits, so please consult your Tufts

Health Freedom Plan Evidence of Coverage 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 First American Administrators. Any missing or incomplete information may result in delay

of payment or the form being returned.

Please complete and send this form to First American

Administrators within one (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.

First American Administrators 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 ID Card or by calling 866-591-1863.

3. First American Administrators 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. Sign the claim form below.

Return the completed form and your itemized paid receipt to:

First American Administrators

Attn: OON Claims

P.O. Box 8504

Mason, OH 45040-7111

Please allow at least 14 calendar days to process your claims once received by First American

Administrators. Your claim will be processed in the order it is received. A check and/or explanation

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

Inquiries regarding your submitted claim should be made to 866-591-1863 or 1-866-308-5375 TDD/TTY

for the hearing and speech impaired.

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

submits an application or files a claim containing a false or deceptive statement is guilty of insurance

fraud.

Vision Services Claim Form - 2016