Get Eyemed Vision Out-of-network Claim Form - Ameritas Group

Filing an out-of-network claim can be straightforward with the right guidance. This comprehensive guide will assist you in completing the EyeMed Vision Out-of-Network Claim Form for Ameritas Group, ensuring you provide all necessary information to facilitate a smooth reimbursement process.

Follow the steps to successfully fill out your claim form.

1. Press the ‘Get Form’ button to obtain the EyeMed Vision Out-of-Network Claim Form. Open it in your preferred online document editor.
2. Begin by entering the date of service in the designated field. Ensure the format is month/day/year.
3. Provide patient information, including last name, first name, middle initial, street address, city, state, zip code, phone number, and birth date. Accuracy is essential for proper identification.
4. Next, complete the vision plan information section. Include the subscriber's last name, first name, middle initial, vision plan name, vision plan ID, and subscriber ID. Reference your benefit ID card if needed.
5. Enter the amounts charged for the services, including the exam, frames, lenses, and contact lenses if applicable. Make sure to attach the itemized paid receipts from your provider.
6. Indicate the type of lenses purchased by circling the appropriate option: single, bifocal, trifocal, or progressive.
7. Review the statement regarding prior authorization. Understand the implications of submitting claims without it.
8. Sign the claim form at the bottom, including the date of signing. This certification confirms the accuracy of the information provided.
9. Finally, you can save your changes, download a copy, print the claim form, or share it as needed for submission.

Complete your EyeMed Vision Out-of-Network Claim Form online today for timely processing of your claim.