Fillable Out-of-Network Claim Form Instructions

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Out-of-Network Claim Form Instructions

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File type: PDF

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Out-of-Network Claim Form Instructions
Thank you for choosing 1-800 CONTACTS. We’re dedicated to providing you with a simple, fast and
hassle-free way to order your contact lenses.
Let’s face it – no one likes paperwork. That’s why we’ve simplified the out-of-network claim process for
you. To receive a check for any money you’re owed, all you need to do is:
1.
Fill in the following form and make sure the information we’ve included is correct.
2.
3.
4.
Please note: Not all insurance plans have out-of-network benefits, so please contact your insurance
company to check benefits from out-of-network providers. Any missing or incomplete information may
result in delay of payment or the form being returned. Your insurance company will notify you if it needs
additional information.
Claims Mailing Addresses
Vision Service Plan (VSP)
Attn: Claims Services
P
.O. Box 385018
Birmingham, AL 35238-5018
Davis Vision
Attn: Vision Care Processing Unit
P
.O. Box 1525
Latham, NY 12110
United Healthcare Vision (Spectera)
Attn: Claims Department
P
. O. Box 30978
Salt Lake City, UT 84130
Sign the form.
Attach an itemized receipt to the form.
Mail the signed, completed form and itemized receipt to your vision insurance company
(contact information included below).
EyeMed Vision Care (same for Aetna Vision
)
Attn: OON Claims
P. O. Box 8504
Mason, OH 45040-7111
Superior Vision
Attn: Claims Processing
P
.O. Box 967
Rancho Cordova, CA 95741
Humana Vision Care Plan
Attn: OON Claims
P
.O. Box 14311
Lexington, KY 40512-4311
Notice to consumers: If you received a cash rebate that does not show up on your original receipt,
make sure you deduct the rebate amount from the total value you submit to your insurance company for
reimbursement.
Out-of-Network Claim Form
1. When using an out-of-network provider, you are responsible for payment of services and/or materials at the time of service. Your
Insurance Plan will reimburse you for authorized services according to your plan benefits.
2. Please complete all sections of this form to help ensure proper benefit allocation.
3. An itemized receipt must be included and indicates 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.
4. Sign the claim form where indicated.
Patient Information (Required)
Last Name
First Name
Middle Initial
Street Address
City
State
Zip Code
Birth Date (MM/DD/YYYY)
- -
Member ID # (if applicable)
Self Spouse Child Other
Subscriber Information (Required)
Last Name
First Name
Middle Initial
Street Address
City
State
Zip Code
Birth Date (MM/DD/YYYY)
- -
Telephone Number
- -
Subscriber ID # (if applicable)
Date of Service (Required) (MM/DD/YYYY)
- -
Provider Name
Provider Phone Number
- -
Request For Reimbursement –Please Enter Amount Charged. Remember to include itemized paid receipts:
Exam
$_________
Frame
$__________
Lenses
$_________
Contact Lenses - (please submit all contact related
$__________ charges at the same time)
If lenses were purchased, please check type: Single Bifocal Trifocal Progressive
I hereby understand that without prior authorization from my insurance carrier for services rendered, I may be denied reimbursement for
submitted vision care services for which I am not eligible under my plan. I hereby authorize any insurance company, organization,
employer, ophthalmologist, optometrist, and optician to release to my vision Insurance Plan any and all information necessary to process 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: ________________
1-800 Contacts
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Fraud Warning Statements
A
rizona: 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.
A
laska: 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.
A
rkansas: 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.
C
olorado: 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.
D
istrict 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.
F
lorida: 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.
G
eorgia: Any person who knowingly, and with intent to defraud any insurance company, files a statement of claim containing any false, incomplete or misleading information may be subject to
criminal penalties.
H
awaii: 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.
I
daho: 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.
I
ndiana: 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.
K
entucky: 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.
M
aine: 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.
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.
M
innesota: 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.
N
ew 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.
N
ew 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.
O
hio: 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.
T
exas: 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.
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Out-of-Network Claim Form Instructions

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Completed 11 August 2020

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