Fillable Out-of-Network Claim Form Instructions (North Carolina Wesleyan College)

Fill Online, Printable, Fillable, Blank Out-of-Network Claim Form Instructions (North Carolina Wesleyan College) Form

Use Fill to complete blank online NORTH CAROLINA WESLEYAN COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Out-of-Network Claim Form Instructions (North Carolina Wesleyan College)

On average this form takes 8 minutes to complete

The Out-of-Network Claim Form Instructions (North Carolina Wesleyan College) form is 2 pages long and contains:

  • 1 signature
  • 14 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

U.S.A. forms for North Carolina Wesleyan College

BROWSE NORTH CAROLINA WESLEYAN COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Out-of-Network Claim Form
Instructions
IMPORTANT INFORMATION
Please read before submitting your out-of-network claim form.
Reimbursements are processed within 60 days from the date we receive your
out-of-network claim form.
Out-of-network claims for services and/or eyewear obtained from an in-network
provider will not be reimbursed.
CEC understands that vision plan members may encounter sales promotions (such as “two-for-one sales”) or
steep discounts offered by some of our optical providers. As is true of most vision plans, your CEC vision plan is
not intended for use in conjunction with these types of offers. In general, providers will allow only one of the
following:
• The CEC vision benefit, or
• The sales promotion (the sale price or discount)
HOW TO FILE AN OUT-OF-NETWORK CLAIM
• Complete this form if, at the time of service, the provider did NOT participate in the CEC network.
• Complete all applicable fields on this form, including the signature. Missing information may delay
processing and reimbursement.
• Submit one claim form for each patient to CEC within 180 days of the date of service.
• Submit a copy of your itemized receipt for each service or product included on this claim form.
• You have a choice of three options for submitting the completed form:
FAX
(704) 413-7098
MAIL
CEC
Attn: Out-of-Network Claims
2359 Perimeter Pointe Parkway, Suite 150
Charlotte, NC 28208
EMAIL
OON@cecvision.com
Out-of-Network Claim Form
PATIENT INFORMATION — Details of the person who received the service
Patient First and Last Name:
Patient’s Relationship to Employee: Self Dependent
Patient Date of Birth:
PRIMARY MEMBER INFORMATION — Employee
Employee First and Last Name:
Employer Name:
Date of Birth:
Member ID#:
CONTACT AND MAILING INFORMATION — Where the reimbursement check should be mailed
Mailing Address:
Phone Number:
Email Address:
REQUEST FOR REIMBURSEMENT — PLEASE CHECK ALL THAT APPLY
Date of service(mm/dd/year): __________________________________________
Eye/Vision Exam ............. Amount Paid: $ _____________________________
Date of service (mm/dd/year): ______________________
Contact Lens Fit / Evaluation Amount Paid: $ _____
COMPLETE BELOW FOR GLASSES
Date of service(mm/dd/year): __________________________________________
Lenses for glasses ............ Amount Paid: $ _____________________________
Frames for glasses ........... Amount Paid: $ _____________________________
Non-prescription sunglasses ….. Amount Paid: $ _________________________
LENS TYPE (check only one)
Single Vision Bifocal Trifocal Progressive Non-prescription
COMPLETE BELOW FOR CONTACTS
Date of service(mm/dd/year): ___________________
Contact Lenses .......... Amount Paid: $ _____________
PROVIDER OR OPTICAL INFORMATION
Name of Provider/Optical:
Address of Provider/Optical:
Phone # of Provider/Optical:
Patient’s or Authorized Person’s Signature: By signing below, I authorize the release of any medical or other information
necessary to process this claim. I have read and agree to CEC’s policies for out-of-network claims outlined on page one of
this document.
Signature _______________________________________________________________ Date __________________________________________
For questions about your out-of-network reimbursement, please call 1-888-254-4290 (Option 2 and then Option 4).
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Out-of-Network Claim Form Instructions (North Carolina Wesleyan College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document