Get Medically Necessary Contact Lens Benefit Eyemed Addendum Form ... - Benefits Mt

Completing the Medically Necessary Contact Lens Benefit EyeMed Addendum Form is essential for the submission of claims related to medically necessary contact lenses. This guide provides a clear, step-by-step approach to ensure that users can easily navigate and fill out the form accurately.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by filling in the provider information section. Include all relevant details such as provider ID, provider location ID, first and last name, address, phone number, email, and fax number. Ensure that the information is accurate and legible.
3. In the patient information section, enter the primary subscriber ID, primary subscriber name, patient name, address, city, state, zip code, plan ID, and the patient's birth date in the format mm/dd/yyyy.
4. For protocol and eligibility, state the date of service in mm/dd/yyyy format. Indicate whether a claim has previously been submitted by checking 'Yes' or 'No'.
5. Complete the fitting information for each eye (OD, OS, OU) and provide the usual and customary fees, excluding the exam fee.
6. Check the applicable conditions under the EyeMed Vision Care medically necessary contact lens protocol. This includes conditions like anisometropia, high ametropia, keratoconus, or vision improvement.
7. Fill in the current refraction prescription, keratometry readings, and contact lens acuity for each eye (OD and OS).
8. Indicate the type of lens to be fitted and have the provider sign and date the form.
9. Once all sections of the form are accurately filled out, you can save changes, download, print, or share the completed form as needed.

Complete your Medically Necessary Contact Lens Benefit EyeMed Addendum Form online today.