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Get Humana Out Of Network Claim Form
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How to fill out the Humana Out Of Network Claim Form online
This guide provides a clear and concise overview of how to fill out the Humana Out Of Network Claim Form. Follow the steps outlined below to ensure that your claim is submitted correctly and efficiently.
Follow the steps to accurately complete your claim form.
- Press the ‘Get Form’ button to access the Humana Out Of Network Claim Form and open it in your preferred document editor.
- Complete the patient information section. Fill in the last name, first name, middle initial, street address, city, state, zip code, birth date, telephone number, and member ID number. Ensure all fields marked as required are properly filled out.
- Continue to the subscriber information section. Enter the subscriber's last name, first name, middle initial, street address, city, state, zip code, birth date, telephone number, vision plan name, vision plan/group ID number, and subscriber ID number.
- Record the date of service in the specified format (MM/DD/YYYY).
- In the reimbursement request section, enter the amount charged for each service received. Detail the costs for the exam, frame, and lenses, along with the type of lenses, if applicable.
- Attach relevant itemized paid receipts from the out-of-network provider to your claim form. It is essential that these receipts clearly list the services provided and amounts charged. Handwritten receipts must be on the provider's official letterhead.
- Include a copy of your Explanation of Benefits if you are submitting the claim for a secondary insurance benefit.
- Sign and date the claim form to certify the information provided is accurate and complete.
- Send the completed form along with the itemized receipts to the provided address: Humana Vision Care Plan, Attn: OON Claims, P.O. Box 14311, Lexington, KY 40512-4311.
- After submission, allow at least 14 calendar days for processing. Check for any correspondence regarding the status of your claim.
Complete the Humana Out Of Network Claim Form online today to ensure a smooth claim process.
Writing a reimbursement claim requires clarity and detail. Use the Humana Out Of Network Claim Form, and be sure to provide a complete breakdown of your expenses, including dates and amounts. A well-organized claim, supported by documentation, increases the likelihood of prompt approval.
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