Get Eyemed Out Of Network Claim Form - Human Resources At Mit - Hr Wayne

The EyeMed Out Of Network Claim Form allows users to request reimbursement for vision services obtained from providers outside the EyeMed network. This guide provides clear instructions on how to fill out the form accurately and submit it effectively for processing.

Follow the steps to complete your claim form successfully.

1. Press the ‘Get Form’ button to access the EyeMed Out Of Network Claim Form and open it for editing.
2. Begin by filling out the patient information section. Provide the required details, including last name, first name, middle initial, street address, city, state, zip code, birth date, telephone number, and member ID number if applicable.
3. In the subscriber information section, enter the subscriber's last name, first name, middle initial, street address, city, state, zip code, birth date, and subscriber ID number if applicable. Additionally, indicate the vision plan name and group number.
4. Complete the 'Request for Reimbursement' section by inputting the amounts charged for each service: exam, frame, lenses, and contact lenses. Ensure that you include itemized paid receipts.
5. If lenses were purchased, check the appropriate boxes for the type of lenses: single, bifocal, trifocal, or progressive.
6. Review the authorization statement. By signing the form, you agree that the information provided is true and that you are aware that reimbursement may be denied for unauthorized services.
7. Sign the form where indicated, and date it.
8. Gather all required itemized paid receipts and attach them along with the completed form. Make sure that receipts are on the provider’s letterhead and, if applicable, indicate any currency differences.
9. Submit your completed form and itemized paid receipts to the address specified: First American Administrators, Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111. Allow at least 14 calendar days for processing once the claim is received.

Start filling out your claim form online today to ensure a smooth reimbursement process.