Fillable Vision Claim Form (Orange County Community College)

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Vision Claim Form (Orange County Community College)

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Country of origin: US
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Part 1: To be completed by Employee
1. Patient’s full name (first, middle initial, last) 2. Patient birthdate (MM/DD/YY)
3. Relationship to employee
Self Spouse Child Other
4. Sex
M F
5. Employee’s full name (first, middle initial, last) 6. Employee’s identification number Employee’s birthdate (MM/DD/YY)
7. Employee’s mailing address (street address or P.O. Box, City, State, ZIP)
Email address:
8. THIS SECTION MUST BE COMPLETED WITH EACH CLAIM SUBMISSION ONLY
IF THE CLAIM IS FOR A DEPENDENT CHILD AGE 19 OR OVER
Is patient a full-time student?
Yes No
If Yes, name
and address
of school:
9. Employer (company)
name and address
10. Group number Division number Certificate number
Questions 11 and 12 must be completed with each claim submission.
11. Is patient covered by
another vision plan?
Yes No
Name and
address of
other carrier
Policy number Name and
address of
other employer:
12. Other employee/subscriber name
Employee/subscriber identification number
Date of birth (MM/DD/YY)
Relationship to patient
13.
I have reviewed the following treatment plan, and I authorize release of
any information relating to this claim. I understand that I am responsible for
all cost of treatment. I certify these statements to be true and complete to
the best of my knowledge.
X
Signature (patient, or parent if minor)
Date
Check one box only:
14A. Please send payment to me OR
14B.
Please pay provider below
X
Signature (insured person)
Date
Part 2: To be completed
by Attending Vision Provider
.
IMPORTANT: Please attach an itemized receipt including provider’s name and address, specific
procedures and materials purchased. If this is attached, you will not need to complete Part 2.
15. Vision care provider name and address
For Yes answers to questions 17-19, enter a brief description and dates.
17. Is treatment result of occupational illness or injury?
Yes No
18. Is treatment result of auto accident?
Yes No
Specialty Phone number
19. Other accident?
Yes No
Email Fax number
20. This is a (please check one):
Statement of actual services
Pretreatment estimate
16. Federal Tax ID Number
SSN
TIN
NPI (National Provider Identifier)
21. Is this for LASIK/PRK? Yes No
License #
22. Date of Service Exam Materials
23. Examination and Treatment Record Please include date of service, description of services, procedure code and fee.
Service CPT Code Fee Lenses CPT Code Fee Options CPT Code Fee
LASIK/
PRK
left eye $
Single
$
Anti-reflective
$
right eye $
Bifocal
$
Scratch resist
$
$ $
Exam
$
Trifocal Tint
Lens fitting
$
Progressive
$
Hi-index
$
Refraction
$
Lenticular
$
Edge polish
$
Other
$
Contacts
$
Other
$
$ Discounts _________________________________Frames $ Other
24. Remarks 25. Total
$
26.
CERTIFICATION: I hereby certify that the services listed above have been performed on
the dates indicated and that the fees subm itted are the fees I have charged and intend to
collect for those purposes.
X
Signature (Provider)
Date
27. Address where treatment was performed
FA 325 Rev. 2-15 02-01-16
vision Group Claim Form
Ameritas Life Insurance Corp. of New York
Group Claims Adjusters / P.O. Box 82595 Lincoln, NE 68501-2595 / Toll Free 800-659-5556 / Fax 402-467-7336 / Web ameritas.com
RESET FORM
tips to speed claims processing
Part 1 – Employee
Missing or incomplete information will slow down claims processing.
Toavoid this, please be sure to include:
#2 – Patient birthdate
Helps identify an insured and determine dependent eligibility.
#6 – Employee’s identification number
This is the most important identifier for the plan member.
#8 – Student status
Because this information often changes, it is required on every claim
for dependents age 19 years and older.
#11 and #12 – Coordination of benefits
The No box under #11 should be checked if no other vision coverage
exists. If there is other vision coverage, the additional information
requested is necessary for coordination of benefits.
Part 2 – Vision Provider
To help expedite the claims process, please be sure to include:
#16 – National Provider Identifier
There are two types of NPI. Type 1 is for individual providers who
operate independently. Type 2 is for health care providers such as
group practices or corporations. Type 2 organization providers may
want their individual provider employees to have Type 1 NPIs to
distinguish them individually.
#21 and #23 – LASIK/PRK
If LASIK or PRK, please make sure your vision provider marks the
Yes box under #21, and includes description of services, procedure
code, which eye (left, right or both), and the fee for each eye in the
Examination and Treatment Record.
#20 – Statement of actual services, or Pretreatment estimate
Appropriate box should be marked to ensure correct handling.
NOTE: If there are two different providers (one for the exam, another
for eyewear), we request that each provider submit a separate
claimform.
Pretreatment Estimate of Benefits
We recommend a pretreatment estimate of benefits when a plan
member considers the services to be expensive. A pretreatment
estimate lets both the member and vision provider know in
advance how much insurance will pay. If vision coverage
terminates for any reason during treatment, only procedures
performed before coverage ended will be eligible for payment.
For full information regarding coverage, plan members may refer
to their insurance plan booklet.
Website
Visit our website for benefit information, electronic forms, a list
of vision providers if your plan includes a network, and more.
Please note, the free software Adobe Reader
®
(available through
the internet) is needed to view and print the electronic forms.
FA 325 Rev. 2-15 02-01-16
Fraud Warning Statements
Alabama: Any person who knowingly presents a false or fraudulent claim
for payment of a 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.
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.
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 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.
Delaware: Any person who knowingly, and with intent to injure, defraud
or deceive 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: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Idaho: Any person who knowingly, and with intent to defraud or deceive
any insurance company, files a statement or 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.
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 thereto commits a fraudulent
insurance act, which is a crime.
Louisiana: 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.
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.
Maryland: Any person who knowingly or willfully presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly or willfully presents
false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
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 is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
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 by 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 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 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 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.
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.
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.
Oregon: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
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.
Rhode Island: 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.
Tennessee: 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, nes and denial of insurance benets.
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.
Vermont: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Virginia: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Washington: 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.
If you live in a state other than mentioned above, the following
statement applies to you: Any person who knowingly, and with intent
to injure, defraud or deceive any insurer or insurance company, files a
statement of claim containing any materially false, incomplete, or misleading
information or conceals any fact material thereto, may be guilty of a
fraudulent act, may be prosecuted under state law and may be subject to
civil and criminal penalties. In addition, any insurer or insurance company
may deny benefits if false information materially related to a claim is provided
by the claimant.
FA 325 Rev. 2-15 02-01-16
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Vision Claim Form (Orange County Community College)

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Completed 20 July 2020

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