Get Eyemed Claim Form - State Of Illinois - State Il

Filing an EyeMed Claim Form can seem overwhelming, especially if you are utilizing an out-of-network vision care provider. This guide provides a clear and comprehensive approach to filling out the EyeMed Claim Form - State Of Illinois - State Il online, ensuring that you provide all necessary information for timely reimbursement.

Follow the steps to successfully complete the claim form.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. Carefully read the instructions included with the form to ensure you understand the requirements for submitting a claim for out-of-network services.
3. Fill in the Date of Service as the first entry. This is usually marked at the top of the form.
4. Complete the Patient Information section by entering the patient's last name, first name, middle initial, street address, city, state, zip code, phone number, and birth date.
5. In the Plan Information section, input the subscriber's name (last name, first name, middle initial), plan name, and subscriber ID. Ensure this information is as it appears on your benefit ID card.
6. Enter the Request for Reimbursement by specifying the amount charged for each service: Exam, Frames, Lenses, and Contact Lenses. Remember to also circle the type of lenses, if applicable.
7. Attach itemized paid receipts from the out-of-network provider. Ensure receipts detail the services received and the amounts paid. For receipts not in US dollars, specify the currency.
8. If you are submitting for a secondary insurance benefit, include a copy of your Explanation of Benefits.
9. If reimbursement is to be sent to someone other than the primary subscriber, include a copy of a canceled check or credit card receipt along with the itemized receipt.
10. Sign the claim form where indicated and enter the date of your signature.
11. Finally, save your changes, and download or print the completed form for submission. You can either fax it to 866-293-7373, email it to oonclaims@eyemedvisioncare.com, or mail it to the provided address.

Complete your claim form online for a smooth and efficient process.