Vision Services Claim Form - 2015 printable pdf download

Administered By First American Administrators

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

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 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 benefit ID card.

3. First American Administrators will only accept itemized paid receipts that indicate the services

provided and the amount charged for each service. The patient name and date of service must be

included on the receipt. 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 receipts 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 the Customer Service number printed on the

back of your benefit identification card.

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 - 2015