Article Guide
When seeking reimbursement for vision care services from an out-of-network provider, the EyeMed Claim Form is an essential tool. This form is necessary only if you choose to visit a non-participating provider, as most EyeMed Vision Care plans allow members to select from both in-network and out-of-network options. However, not all plans include benefits for out-of-network services, so reviewing your benefits documentation is crucial before proceeding. Completing the claim form accurately is vital; any missing information can delay your reimbursement. You must include itemized receipts from your provider that detail the services rendered and the costs associated with each service. It’s also important to note that you must pay the provider in full at the time of service. The form includes sections for patient and provider information, along with details about the services rendered, so gathering all necessary receipts and information prior to submission can streamline the process. Finally, it is advisable to send your completed form to EyeMed within one year of your visit to avoid complications. Whether you are submitting the claim via fax, email, or traditional mail, following the guidelines precisely will enhance the likelihood of a swift reimbursement.
Form Sample
Most EyeMed Vision Care plans allow members the choice to visit an
If you choose an
1.When visiting an
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.
5.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.
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.
Please indicate to whom the reimbursement should be sent: |
Subscriber |
Patient |
6.Sign the claim form where indicated.
Date of Service: _____________________ |
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Patient Information: |
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Last Name: _________________ First Name: ______________ |
MI: ______________ |
Street Address: _________________________________________________________________
City: ______________________ |
State: _________________ |
Zip: ______________ |
Phone: _____________________ |
Birth Date: ________________ |
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Plan Information: |
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Subscriber Name |
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Last:________________________ |
First: ________________ |
MI: ______________ |
Plan Name: ___________________________________________________________________
Subscriber ID: ________________
Request For Reimbursement
Exam: |
Frames: |
Lenses: |
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Contact Lenses – (includes fit and |
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$_______ |
$______ |
$________ |
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$__________ |
all contact related charges at the same time) |
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If lenses were purchased, please SELECT type: |
Single |
Bifocal |
Trifocal |
Progressive |
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I hereby understand that without prior authorization form 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: |
To Email Form and Receipts: [email protected] |
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To Mail: |
EyeMed Vision Care Attn: OON Claims |
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P.O. Box 8504 |
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Mason, OH |
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Fraud Warning Statements
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud a policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Department of Insurance within the department of regulatory agencies.
District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
Idaho: Any person who knowingly and with intent to defraud or deceive any insurance company, files a statement or claim containing a false, incomplete or misleading information is guilty of a felony.
Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application or claim for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime.
Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in § 638.20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York: Any person who knowingly and with intent to defraud insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
Ohio: Any person who, with intent to defraud, or knowing that he is facilitating a fraud against an insurer, submits an application or false claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Document Specifications
| Fact Name | Description |
|---|---|
| Claim Form Purpose | This form is for members using out-of-network vision care providers. It is not needed for in-network services. |
| Out-of-Network Benefits | Not all EyeMed plans include out-of-network benefits. Members should check their plan details before proceeding. |
| Timely Submission | The completed claim form must be sent to EyeMed within one year from the original date of service. |
| Payment Responsibility | Members must pay for services and materials at the out-of-network provider's office at the time of service. |
| Receipt Requirements | Itemized paid receipts are required. They must detail services rendered and amounts charged, and be on the provider's letterhead. |
| Secondary Insurance | For claims involving secondary insurance benefits, attach a copy of the Explanation of Benefits. |
| Reimbursement Designation | If the reimbursement is to be sent to someone other than the primary subscriber, additional supporting documentation is required. |
| Signature Requirement | Claimants must sign the form verifying the truth of the information provided and acknowledging responsibility for any errors. |
| Fraud Warnings | Each state has specific laws addressing fraudulent claims. Familiarity with these is vital when submitting a claim. |
| Contact for Submission | Claims can be submitted via fax, email, or standard mail to EyeMed. Ensure all required documentation is attached. |
Steps to Filling Out Eyemed Claim
Completing the EyeMed Claim Form is straightforward but requires attention to detail. Ensure that you gather all necessary information and receipts before starting the process. By following these steps, you will provide EyeMed with all required details, which helps in expediting the reimbursement process.
- Start by visiting your out-of-network provider, where you will pay for all services at the time they are rendered.
- Obtain your member benefits information from your benefit ID card or human resources department. This will help with filling in the plan information correctly.
- Visit the claim form and fill out every section completely. Missing information may delay your reimbursement.
- Attach itemized paid receipts from your provider. Make sure these receipts clearly show the services provided and their corresponding costs. If you paid in a currency other than U.S. dollars, note the currency used.
- If you are submitting a claim for a secondary insurance benefit, include a copy of your Explanation of Benefits.
- If the reimbursement should go to someone other than yourself, include either a copy of a canceled check or credit card receipt, along with the paid itemized receipt. Cash payment receipts are also acceptable.
- Clearly indicate who should receive the reimbursement—whether it is the subscriber or the patient.
- Sign the claim form where indicated, confirming that all information provided is true and accurate.
- Finally, date the claim form before submission.
Once completed, you can choose to fax the form to EyeMed, email it with the receipts attached, or mail it to the specified address. Be sure to keep copies of everything for your records. Submitting the form promptly within one year from the original date of service is crucial to receive your benefits without delay.
More About Eyemed Claim
What is the EyeMed Out-Of-Network Claim Form used for?
The EyeMed Out-Of-Network Claim Form is designed for members who choose to visit a vision care provider that is not part of EyeMed’s network. While many EyeMed plans allow for this choice, not all offer out-of-network benefits. Before using the form, it's important to confirm your coverage details through your member benefits information or your human resources department.
What steps should I follow when submitting a claim?
When submitting a claim, there are a few key steps to follow. First, ensure that you pay your out-of-network provider for the services rendered at the time you receive care. Afterward, complete the claim form thoroughly, as missing information can cause delays or lead to the form being returned. You must submit the completed form to EyeMed within one year of the service date. Remember to include any required documentation, such as itemized paid receipts, to support your claim.
What types of receipts are required for the claim?
EyeMed requires itemized paid receipts that list the services provided along with the corresponding charges. These receipts must reflect full payment for services to be eligible for reimbursement. If you have a handwritten receipt, it needs to be on the provider’s letterhead. Also, if the payment was made in a currency other than US dollars, you must specify the currency used.
Do I need to submit anything if I have secondary insurance?
If you have secondary insurance and wish to submit a claim for reimbursement from it, you must include a copy of your Explanation of Benefits (EOB) along with your claim form. This helps ensure that both insurance providers are aware of the services being claimed and can process your claim accordingly.
How do I indicate where the reimbursement should be sent?
The claim form includes a section where you specify to whom the reimbursement should be directed—either to the subscriber (you) or to the patient (if different). If the reimbursement is meant for someone else, be sure to include verification of that individual’s entitlement, such as a canceled check or a credit card receipt, along with the itemized paid receipt.
What happens if I don’t include all the necessary information?
If your claim form is incomplete, or if the required documentation is missing, you risk experiencing delays in reimbursement. Additionally, EyeMed may return your claim for corrections. It's always best to double-check that all information is filled out correctly and that all necessary attachments are included before submitting your form.
Common mistakes
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Failing to check coverage limitations. Before submitting a claim, it’s essential to verify whether your specific plan includes out-of-network benefits. Neglecting this step may lead to unexpected out-of-pocket expenses.
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Not completing all required sections. A common mistake is leaving sections of the claim form blank. Every field should be filled out accurately to prevent delays or denials in processing.
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Submitting unitemized receipts. EyeMed requires itemized paid receipts that clearly list the services provided. Always ensure your receipts include these details and are on the provider's letterhead.
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Ignoring the currency of payment. If your receipt is not in US dollars, you must specify the currency. Failure to do so can result in confusion and delays in reimbursement.
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Omitting necessary documentation. When applying for a secondary insurance benefit, always include a copy of your Explanation of Benefits. This document is crucial for verifying prior payments and coverage.
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Forget to sign the claim form. It’s easy to overlook this step, but signing is essential to validate your claim. Your signature confirms the accuracy of the information provided.
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Not submitting within the deadline. Claims must be submitted within a year from the date you received services. Late submissions will not be processed.
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Choosing the wrong recipient for reimbursement. If the payment is to be sent to someone other than the primary subscriber, additional documentation like a cancelled check is needed. Be clear about who should receive the funds.
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Using handwritten receipts incorrectly. Handwritten receipts must be formatted correctly. Ensure they are on the provider’s official letterhead to be considered valid.
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Assuming all information is correct without double-checking. Errors in patient names, dates, or plan information can lead to claim rejection. Always review your submission for accuracy.
Be sure to keep these common mistakes in mind when filing your EyeMed claim. By paying attention to detail and ensuring you meet all requirements, your experience can be much smoother.
Documents used along the form
When submitting an EyeMed Claim form, you may need additional documents to ensure a smooth reimbursement process. Below is a list of forms commonly required in conjunction with the claim form, each serving an important purpose.
- Itemized Paid Receipts: These receipts detail the services rendered by the out-of-network provider and the amounts charged. Only itemized receipts presented on the provider’s letterhead are acceptable.
- Explanation of Benefits (EOB): If applicable, this document outlines the benefits paid by your primary insurance. Include it when claiming benefits from a secondary insurance provider.
- Cancellation Check or Credit Card Receipt: Necessary if the reimbursement is directed to someone other than the primary subscriber. This document confirms payment for services.
- Proof of Payment: A cash receipt is also acceptable as proof of payment for the services. Ensure its details are clearly legible.
- Benefit ID Card: This card conveys important plan information needed when filling out the claim form. Keep it handy for reference.
- Authorization Form: This form may be required by your insurance provider for certain services. Check with your provider to see if this applies.
- Policy Documents: These documents outline your coverage. Refer to them while completing the claim form to ensure correct information is included.
- Contact Information for the Provider: Include contact details of the out-of-network provider, in case EyeMed requires additional verification.
- Claim Submission Letter: A simple cover letter summarizing your claim and attaching required documents may aid in quick processing.
Gather these documents to facilitate your claim process. Missing information might lead to delays or rejection of your claim. Ensure all submissions are sent within the deadlines imposed by EyeMed. Your attention to detail can make a significant difference in obtaining your reimbursement efficiently.
Similar forms
The Healthcare Claim Form (CMS-1500) is a widely used document for medical claims filed by healthcare providers. Similar to the EyeMed Claim Form, the CMS-1500 requires detailed patient and provider information. Both forms necessitate itemized lists of services or treatments rendered and associated costs. Furthermore, both documents must be submitted within defined timeframes to ensure timely reimbursement, emphasizing the importance of both accuracy and completeness in filling them out to avoid payment delays.
The Prescription Drug Claim Form serves as another comparable document. Like the EyeMed Claim Form, it is designed for members who utilize non-participating pharmacies. Patients submit receipts for prescription medications along with relevant personal and plan information. Both forms also require an indication of the reimbursement amount requested. Ensuring all necessary receipts are attached is critical for both forms, as omissions can lead to claim denials.
The Dental Claim Form is similar, catering to dental services. Patients provide information about the dental provider, treatments received, and expenses incurred, much like on the EyeMed Claim Form. Both forms demand detailed descriptions of services. Additionally, timeliness in submission is crucial, making sure that claims are sent within a specified period to avoid rejection or delays in reimbursement.
The Vision Care Services Claim Form offers another parallel, designed for various vision care claims. Just as with the EyeMed Claim Form, it requires the member's identification along with specifics about the eye care services utilized. Patients must also include receipts from providers to support their claims. Both documents ensure that insurers have all necessary information to process claims correctly, reinforcing the need for detail and accuracy.
Finally, the Out-of-Network Provider Claim Form from other insurance companies mirrors the EyeMed Claim Form in that it is specifically for members utilizing services outside of their insurance network. Like the EyeMed form, it requires detailed patient information, service descriptions, and itemized billing receipts to substantiate reimbursement requests. Each document underscores the importance of full disclosure and compliance with submission guidelines to facilitate prompt payment from insurers.
Dos and Don'ts
When filling out the EyeMed Claim form, it’s important to adhere to specific guidelines to ensure a smooth process. Here’s what to do and what to avoid.
Things You Should Do:
- Complete all sections of the form to guarantee proper benefit allocation.
- Attach itemized paid receipts from the provider, showing both services and charges.
- Ensure receipts are in US dollars, or state the currency of payment.
- Submit the claim within 1 year from the service date to avoid delays.
Things You Shouldn't Do:
- Do not leave any sections of the form blank, as this may lead to processing delays.
- Avoid using handwritten receipts that are not on the provider’s letterhead.
- Do not submit claims without proof of full payment for services.
- Refrain from signing the form unless all information is accurate and true.
Misconceptions
Understanding the EyeMed Claim form can be a bit daunting, and several misconceptions often arise regarding its use. Addressing these misunderstandings is critical for ensuring a smooth and efficient claim process. Here are four common misconceptions that members might have:
- All vision care plans offer out-of-network benefits. Many individuals mistakenly believe that all EyeMed plans provide benefits for services rendered by non-participating providers. In reality, not all plans include out-of-network coverage. It is essential to consult your member benefits information to determine your specific coverage for such services.
- You do not have to pay the provider upfront when using out-of-network services. Some members think they can submit a claim without paying for services at the time of the appointment. However, when visiting an out-of-network provider, you are responsible for covering the cost upfront. EyeMed will reimburse you afterward based on the specifics of your plan.
- Informal receipts are acceptable for claiming reimbursement. It is a common misconception that any form of receipt will suffice for reimbursement claims. EyeMed requires itemized paid receipts that detail the services provided and the associated costs. For reimbursement to occur, these receipts must indicate full payment for the services rendered.
- The claim form can be submitted at any time after service. Some individuals believe they can submit claims at their convenience. However, members must submit the completed claim form within one year from the original date of service. Delays in submission may lead to denial of the claim.
By clarifying these misconceptions, members can better navigate the claims process and ensure they receive the benefits they deserve.
Key takeaways
When filing out the EyeMed Claim Form, it’s essential to follow the guidelines carefully to ensure a smooth reimbursement process. Here are key takeaways to keep in mind:
- Out-of-Network Requirement: Use this form only when visiting a provider not part of the EyeMed network. If your plan does not have out-of-network benefits, check your member benefits.
- Payment Responsibility: You will need to pay for all services at the time of your appointment. EyeMed will reimburse you afterward according to your plan’s terms.
- Complete All Sections: Fill out every part of the claim form accurately. Incomplete forms can result in payment delays.
- Itemized Receipts are Necessary: Submit itemized paid receipts with your claim. These must show the services provided and the amounts charged.
- Handwritten Receipts: If submitting a handwritten receipt, it must be on the provider’s official letterhead.
- Use Correct Currency: If the receipt is not in US dollars, include a note indicating the original currency.
- Explain Secondary Insurance: If you’re submitting for a secondary insurance benefit, attach a copy of your Explanation of Benefits.
- Reimbursement Address: Indicate whether the reimbursement should go to the subscriber or the patient and provide necessary documentation if sent to someone else.
- Timeframe for Submission: Submit the claim form within one year from the date of service to ensure eligibility for reimbursement.
Following these points will help ensure that your claim is processed efficiently and without unnecessary delays. Keep this list handy as you work through your EyeMed claim process.