Get Blue View Vision Out-of-network Claim Form - Anthem

Filling out the Blue View Vision Out-of-Network Claim Form is essential for users seeking reimbursement for vision services provided by an out-of-network provider. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your out-of-network claim form successfully.

1. Click the ‘Get Form’ button to obtain the claim form. This will allow you to access the document in an editable format.
2. Provide the patient information in the required fields. This includes the last name, first name, middle initial, street address, city, state, zip code, birth date, and telephone number.
3. Enter the member ID number and the relationship to the subscriber, such as self, spouse, child, or other.
4. Fill in the subscriber information, including their last name, first name, middle initial, street address, city, state, zip code, birth date, telephone number, and vision plan details such as the vision plan name and ID number.
5. Indicate the date of service in the specified format (MM/DD/YYYY) and provide the subscriber ID number.
6. Enter the amount charged for the requested reimbursement in the appropriate fields for exam, frame, lenses, and contact lenses, if applicable. Make sure to include a total based on your itemized paid receipts.
7. Read and understand the statement regarding possible denial of reimbursement for ineligible services. Provide your signature and the date in the designated area to certify the information provided is accurate.
8. Once all sections of the form are completed, review the form for any missing or incomplete information before submitting.
9. Return the completed form along with your itemized paid receipts by mailing, faxing, or emailing it to the appropriate contact provided in the instructions.
10. After submission, please allow at least 14 calendar days for your claim to be processed. Expect a check or explanation of benefits to arrive within seven calendar days of processing.

Begin filling out your Blue View Vision Out-of-Network Claim Form online now.