Out of Network Vision Services Claim Form

Transcript

1 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Claim submissions made easy WENT OUT-OF-NETWORK? NO PROBLEM, T’S WALK THROUGH IT LE If you saw an out-of-network eye doctor and you have out-of-network benefits, your next step is to send us your c ompleted claim form. You can now submit your form online or by mail: Online By mail –OR– Complete and return the Click below to complete an electronic claim form. Go following paperwork. green and get paid faster. If you will be using electronic assistive devices to complete the form, please use the online form. Claim forms must be submitted within 15 months of the date of service. For complete terms and conditions, review the claim form. Stay in-network and save on your next visit* CH OOSE AN EYE DOC Wi th thousands of providers across the nation, you can see who you want to see, when and where you want to see them. Whether it’s an independent eye doctor, popular retailer or even online, you have options. Ea sily find an eye doctor on eyemed.com or on the EyeMed Members App. Search by location, store hours and more—and then schedule your appointment.** WA TCH IT ADD UP Me mbers who combine an eye exam and new glasses †† save an average of 72% off retail prices.

2 NE VER PAY STICKER PRICE † et discounts like: Pock • 40% off additional pairs 20% off non-prescription sunglasses • • Up to 20% off anything above your frame allowance FORM-FREE Wh en you stay in-network, it’s easy to get an eye exam and get on with your day. No paperwork. No hassles. SEE THE GOOD STUFF Register on eyemed.com or grab the member app (App Store or Google Play) now. *Vision care services frequency may vary. Check your benefits to verify your frequency of services type. **At select in-network † providers. Discounts available at participating in-network providers. †† Discounts and benefits may vary. Check your benefits. Savings comparison of EyeMed versus care without vision benefits. PDF-1806-M-641

3 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Claim Form Instructions To request reimbursement, please complete and sign the itemized claim form. Return the completed form and your itemized paid receipts to: First American Administrators, Inc. Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111 † † Patient Last Name MI Patient First Name † † Street Address Birth Date (MM/DD/YYYY) † † † State Zip Code City Relationship to Subscriber Patient Member ID # Dependent Self † Doctor or Store Name where you received service † † Subscriber Last Name Subscriber First Name MI Birth Date Street Address (MM/DD/YYYY) State City Zip Code † Vision Plan Name Date of Service (MM/DD/YYYY) Subscriber Member ID # Vision Plan Group # † Required 1 continued

4 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Request for Reimbursement † † Enter Amount Charged. Remember to include itemized paid receipts. Amount Amount Lens Options: Please Service Type Lens Type Charged (if purchased) Charged Check Single Anti-Reflective Exam $ $ *V2100* *92014* *V2750* Bifocal Polycarbonate Refraction $ $ *V2200* *V2784* *92015* Trifocal Scratch Frame $ $ *V2300* *V2760* *V2025* Progressive Contact Lens Tint $ $ *V2781* * V274 5* *S0500* Prem Prog UV Contact Lens $ $ *V278126* *92310* *V2755* Fitting Other Lenses Roll and Polish $ $ *V2702* $ Enter Total Amount Paid as shown on receipt, $ † excluding sales tax 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. By signing this claim form, I certify that I have read the applicable claim fraud warnings included with this form, and that all the information furnished by me is true and correct. † Date Member/Guardian/Patient Signature (not a minor) † Required 2 continued

5 ORM OU ON S ERVICES C LAIM F ISI T-OF-NETWORK V Netw ork Acc ess Exceptions We work har d to make sur e that you have acc ess to thousands o f e ye doctors across , you may the nation. Whe s due to location or pr ovider av ailability ther it’ need to go out-of-netw ork to receive care. If this applies to you, please complete the following form. If not, please skip this section. office location, Based from your home or may you have the right to obtain in-network level of benefits with an out-of-network visit provider when: (i) you cannot schedule a within two-weeks, (ii) you are unable to locate a participating provider within a 10-mile radius in an urban-suburban area, or (iii) you are unable to locate a participating provider Y within a 20-mile radius in a rural area. ou must submit a claim form to EyeMed for reimbursement. Caution, this option is not available when you choose to use an out-of-network provider due your preference, (ii) when your personal schedule does not permit you to to (i) schedule an appointment with an available provider in two-weeks, (iii) or you are outside of your home or office location. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim of insurance fraud. guilty containing a false or deceptive statement is 3 continued

6 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Check the boxes that apply. I acknowledge that I fit into one or more of the following criteria: I was unable to schedule a visit within two-weeks with a participating provider. Please provide the participating provider’s name, location and contact information in which you attempted to schedule an appointment: Provider Telephone Number (000-000-0000) Provider’s Name Provider Street Address State City Zip Code I was unable to locate a participating provider within a 10-mile radius in an urban-suburban area. Please provide the zip code in which you were attempting to locate a provider: Zip Code OR I was unable to locate a participating provider within a 20-mile radius in a rural area. Please provide the zip code in which you were attempting to locate a provider: Zip Code Should you fail to provide the requested information associated with the criteria you selected above, you agree that we can process your claim as an out-of-network claim. 4 continued

7 Revision date 04/12/18 OUT-OF-NETWORK VISION SERVICES CLAIM FORM State Fraud Warning Statements General Fraud Warning: 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 and may be subject to fines and confinement in prison. For the states of AL, AK, AZ, AR, CA, CO, DE, DC, FL, GA, HI, ID, IN, KS, KY, LA, MA. MD, ME, MN, NC, NE, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA and WV, please refer to the following fraud notices: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. 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. For your protection, Arizona law requires the following statement to appear on Arizona: this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of 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 the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. 5 continued

8 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Any person who knowingly, and with intent to injure, defraud or deceive Delaware: any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. 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. Georgia, Vermont: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. 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. Any person who knowingly, and with intent to defraud or deceive any insurance Idaho: company, files a statement of claim containing any 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. Kansas: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud as determined by a court of law. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime. It is a crime to knowingly provide false, incomplete or Maine, Tennessee, Washington: misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. 6 continued

9 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Massachusetts: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Nebraska: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false, incomplete or misleading information is guilty of insurance fraud. 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 RSA 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 York: Any person who knowingly and with intent to defraud any 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 material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. 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. Any person with the intent to injure, defraud, or deceive an insurer or North Carolina: insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties. 7 continued

10 OUT-OF-NETWORK VISION SERVICES CLAIM FORM Ohio: 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. WARNING: Any person who knowingly, and with intent to injure, defraud or Oklahoma: 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. Any person who knowingly, and with intent to defraud any insurance company Oregon: or other persons 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, may be subject to prosecution for insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any 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 insurance act, which is a crime and subjects such person to criminal and civil penalties. Any person who knowingly and with the intention of defrauding presents false Puerto Rico: information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand ($5,000) and not more than ten thousand ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Virginia: Any person who, with the 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 may have violated state law. 8

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