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 astwo-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:
Patients 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
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