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The Blue Vision Claim form is an essential tool for members looking to reimburse expenses incurred from out-of-network eye care services. When you visit an out-of-network eye doctor, having the right claim form is your next step toward getting reimbursed. This form allows you to submit your claims via mail or online, simplifying the process considerably. To ensure a hassle-free experience, make sure to complete the form accurately and include the required itemized receipts. Remember, claims must be submitted within 12 months of the service date. Whether you’re utilizing electronic devices or opting for traditional methods, the form is designed for convenience. It captures your essential details, such as personal information and the specifics of your eye care visit, ensuring that you meet all necessary requirements for reimbursement. Knowing your out-of-network benefits can save you money. Additionally, using in-network providers can lead to further discounts and ease; in-network visits often come with no paperwork at all. So, whether you're focused on cost savings or just navigating the claims process, understanding how the Blue Vision Claim form works will empower you to make informed decisions.

Blue Vision Claim Example

Blue View VisionSM

Claim submissions made easy

If you saw an out-of-network eye doctor and you have out-of-network benefits, your next step is to send a completed out-of-network claim form. Here’s how:

Online

–OR– By mail

Click below to complete

Complete and

an electronic claim

return the following

form. Go green and

paperwork.

get paid faster.

 

Access Form

If you will be using electronic assistive devices to complete the form, please use the online form.

Claim forms must be submitted within 12 months of the date of service. For complete terms and conditions, review the claim form.

Stay in-network and save on your next visit*

CHOOSE AN EYE DOCTOR

With thousands of providers across the nation, you can see who you want to see, when and where you want to see them. Whether it’s an independent eye doctor, popular retailer or even online, you have options.

Easily find an eye doctor using the provider locator on your vision benefit member homepage. Search by location, store hours and more — and then schedule your appointment.**

PDF-1806-RM-646

WATCH IT ADD UP

Members who combine an eye exam and new glasses save an average of 72% off retail prices. †

NEVER PAY STICKER PRICE

Receive additional discounts like:††

•40% off additional pairs

•20% off non-prescription sunglasses

•Up to 20% off anything above your frame allowance

FORM FREE

When you stay in-network it’s easy to get an eye exam and get on with your day. There’s no paperwork to fill out or forms to file. Everything is done for you.

*Vision care services frequency may vary. Check your benefits to verify your frequency of services type. **At select in-network providers. †Savings comparison of EyeMed versus care without vision benefits. ††Discounts are not insured benefits and are available at participating in-network providers. Not all discounts are available at all provider locations. Discounts and benefits may vary. Check your benefits.

OUT OF NETWORK/INDEMNITY

Blue View VisionSM

VISION SERVICES CLAIM FORM

 

Claim Form Instructions

To request reimbursement, please complete and sign the itemized claim form. Return the completed form and your itemized paid receipts to:

Email: oonclaims@eyewearspecialoffers.com | Fax: 866-293-7373

Mail: Blue View Vision, Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111

Patient Last Name†

 

Patient First Name†

 

MI

 

 

 

 

 

Birth Date (MM/DD/YYYY)† Street Address†

City†

 

 

State†

 

Zip Code†

 

 

 

 

 

 

Patient Member ID #

Relationship to Subscriber

 

Self

Dependent

 

 

 

 

 

 

 

 

Doctor or Store Name where you received service†

Subscriber Last Name†

 

 

 

Subscriber First Name†

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

Birth Date (MM/DD/YYYY)

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Vision Plan Name

 

 

Date of Service† (MM/DD/YYYY)

 

 

 

 

 

Vision Plan Group #

 

 

 

Subscriber Member ID #

 

 

 

 

 

 

 

 

 

†Required

 

 

 

 

 

 

 

continued 1

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Request for Reimbursement

Enter Amount Charged.† Remember to include itemized paid receipts.†

Service Type

Amount

 

Lens Type

Please

Lens Options:

Amount

Charged

 

Check

(if purchased)

Charged

 

 

 

 

 

 

 

 

 

 

 

 

Exam

$

 

 

Single

 

 

 

 

Anti-Reflective

$

 

 

 

 

 

 

 

 

*92014*

 

 

 

*V2100*

 

 

 

 

*V2750*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refraction

$

 

 

Bifocal

 

 

 

 

Polycarbonate

$

 

 

 

 

 

 

 

 

*92015*

 

 

 

*V2200*

 

 

 

 

*V2784*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frame

$

 

 

Trifocal

 

 

 

 

Scratch

$

 

 

 

 

 

 

 

 

*V2025*

 

 

*V2300*

 

 

 

 

*V2760*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Lens

$

 

 

Progressive

 

 

 

 

Tint

$

 

 

 

 

 

 

 

 

*S0500*

 

 

 

*V2781*

 

 

 

 

*V2745*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Lens

$

 

 

Prem Prog

 

 

 

 

UV

$

 

 

 

 

 

 

 

 

Fitting *92310*

 

 

 

*V278126*

 

 

 

 

*V2755*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lenses

$

 

 

Other

$

 

 

 

Roll and Polish

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*V2702*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter Total Amount Paid as shown on receipt,

$

 

 

excluding sales tax†

 

 

 

 

 

 

I hereby understand that without prior authorization from Blue View Vision Care LLC for services rendered, I may be denied reimbursement for submitted vision care services for which I am not eligible. I hereby authorize any insurance company, organization employer, ophthalmologist, optometrist and optician to release any information with respect to this claim. By signing this claim form, I certify that I have read the applicable claim fraud warnings included with this form, and that all the information furnished by me is true and correct.

Member/Guardian/Patient Signature (not a minor)†

 

Date

 

 

 

†Required

continued 2

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Network Access Exceptions

We work hard to make sure that you have access to thousands of eye doctors across the nation. Whether it’s due to location or provider availability, you may need to go out-of-network to receive care.

If this applies to you, please complete the following form. If not, please skip this section.

Based from your home or office location, you have the right to obtain in-network level of benefits with an out-of-network provider when: (i) you cannot schedule a visit within two-weeks, (ii) you are unable to locate a participating provider within a 10- mile radius in an urban-suburban area, or (iii) you are unable to locate a participating provider within a 20-mile radius in a rural area. You must submit a claim form to EyeMed for reimbursement.

Caution, this option is not available when you choose to use an out-of-network provider due to (i) your preference, (ii) when your personal schedule does not permit you to schedule an appointment with an available provider in two-weeks, (iii) or you are outside of your home or office location. Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

continued 3

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Check the boxes that apply. I acknowledge that I fit into one or more of the following criteria:

I was unable to schedule a visit within two-weeks with a participating provider.

Please provide the participating provider’s name, location and contact information in which you attempted to schedule an appointment:

 

Provider Telephone

Provider’s Name

Number (000-000-0000)

 

Provider Street Address

City

State

Zip Code

I was unable to locate a participating provider within a 10-mile radius in an urban-suburban area.

Please provide the zip code in which you were attempting to locate a provider:

Zip Code

OR

I was unable to locate a participating provider within a 20-mile radius in a rural area.

Please provide the zip code in which you were attempting to locate a provider:

Zip Code

Should you fail to provide the requested information associated with the criteria you selected above, you agree that we can process your claim as

an out-of-network claim.

continued 4

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

State Fraud Warning Statements

Revision date 04/12/18

General Fraud Warning: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison.

For the states of AL, AK, AZ, AR, CA, CO, DE, DC, FL, GA, HI, ID, IN, KS, KY, LA, MA. MD, ME, MN, NC, NE, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA and WV, please refer to the following fraud notices:

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona: For your protection, Arizona law requires the following statement to appear

on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California: For your protection, California law requires the following to appear on this

form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company

who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

continued 5

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Georgia, Vermont: Any person who with intent to defraud or knowing that he/ she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Kansas: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud as determined by a court of law.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime.

Maine, Tennessee, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

continued 6

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Nebraska: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false, incomplete or misleading information is guilty of insurance fraud.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

North Carolina: Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.

continued 7

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon: Any person who knowingly, and with intent to defraud any insurance company or other persons files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, may be subject to prosecution for insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand ($5,000) and not more than ten thousand ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

8

Get Blue Vision Claim PDF Form

Form Characteristics

Fact Name Description
Out-of-Network Benefits The Blue Vision Claim form allows members to request reimbursement for services received from out-of-network eye doctors.
Submission Methods You can submit the completed claim form either online or by mail, offering flexibility based on your preferences.
12-Month Submission Deadline Claims must be submitted within 12 months from the date of service, ensuring timely processing of expenses.
Electronic Assistive Devices If you are using electronic devices to fill out the form, it is recommended to use the online form for convenience.
Accessing the Form The claim form can be accessed directly via the Blue View Vision member homepage, making it easy to find.
Claims Support Contact For any inquiries, members can email oonclaims@eyewearspecialoffers.com or fax claims to 866-293-7373.
Required Information Members must provide essential details such as member ID, service date, and itemized receipts for successful claim processing.
Network Access Exceptions You may qualify for in-network benefits with an out-of-network provider if you cannot see a participating provider within specified distances or timeframes.
Fraud Warning The form includes warnings regarding insurance fraud, emphasizing honesty in the provided information.
State-Specific Governing Laws The specifics of the governing laws for claim submissions can vary by state, so residents should verify their local regulations.

Guidelines on Utilizing Blue Vision Claim

Completing the Blue Vision Claim form is essential for reimbursement after visiting an out-of-network eye doctor. Ensure that all required information is filled out accurately to avoid delays. Follow these instructions carefully to submit your claim correctly.

  1. Access the Blue Vision Claim form through the provided link.
  2. Choose to complete the form either online or by printing it for mail submission.
  3. Fill in your personal information such as:
    • Patient Last Name
    • Patient First Name
    • Middle Initial
    • Birth Date (MM/DD/YYYY)
    • Street Address
    • City
    • State
    • Zip Code
    • Patient Member ID #
    • Relationship to Subscriber (Self or Dependent)
  4. Provide the doctor or store name where the service was received.
  5. Complete the subscriber's information including:
    • Subscriber Last Name
    • Subscriber First Name
    • Middle Initial
    • Birth Date (MM/DD/YYYY)
    • Street Address
    • City
    • State
    • Zip Code
    • Vision Plan Name
    • Date of Service (MM/DD/YYYY)
    • Vision Plan Group #
    • Subscriber Member ID #
  6. List the services received and enter the amounts charged for each service based on your itemized paid receipts. Ensure to include:
    • Exam
    • Refraction
    • Frame
    • Contact Lens Fitting
    • Any additional charges
  7. Calculate the total amount paid, excluding sales tax, as shown on your receipt.
  8. Sign and date the claim form to certify that the information provided is accurate and true.
  9. Submit the completed form and itemized paid receipts via email, fax, or mail to the appropriate address:
    • Email: oonclaims@eyewearspecialoffers.com
    • Fax: 866-293-7373
    • Mail: Blue View Vision, Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111

What You Should Know About This Form

What is the Blue Vision Claim form and when should I use it?

The Blue Vision Claim form is a document you need to complete if you have received vision care services from an out-of-network provider and wish to request reimbursement. You should use this form when you have out-of-network benefits and have seen an eye doctor who is not part of the Blue View Vision network. Claims must be submitted within 12 months from the date of service to be eligible for reimbursement.

How can I submit my claim form?

You can submit your completed claim form online or by mail. To submit online, complete the electronic claim form found on the Blue View Vision member homepage. If you choose to submit by mail, you should send the completed claim form along with your itemized paid receipts to the specified address. You can also provide your forms via email or fax for additional convenience.

What information do I need to include on the claim form?

Ensure you provide all required personal details including your name, date of birth, and member ID. You will also need to provide information about the out-of-network provider, the date of service, and an itemized list of the services received along with the corresponding charges. Itemized paid receipts are necessary to facilitate your reimbursement, so make sure to keep them.

Can I receive reimbursement if I used out-of-network services?

Yes, you can receive reimbursement for out-of-network services, but you will need to follow the submission process using the Blue Vision Claim form. Remember to provide all the necessary documentation and ensure that you submit your claim within the designated timeframe to avoid any issues.

What if I have trouble finding an in-network provider?

If you cannot find an in-network provider due to location or availability, you may still be eligible for out-of-network benefits. You have the right to obtain in-network level benefits with an out-of-network provider under specific conditions. These conditions include being unable to schedule an appointment within two weeks or not being able to locate a participating provider within a certain distance from your home or office. In this case, you will still need to complete the claim form for reimbursement.

What happens if I submit incorrect information on my claim form?

Submitting incorrect information may lead to delays or denial of reimbursement. It’s crucial to ensure that all the details you provide on the claim form are accurate. If you submit a false claim or information that is intentionally misleading, this could also be considered insurance fraud, which is a serious offense. Always double-check the information before submitting.

Common mistakes

Filling out the Blue Vision Claim form can seem straightforward, but common mistakes can lead to delays in processing your claim. One of the most important errors to avoid is not including all required information. Omitting critical details such as your Patient Member ID or Date of Service can result in your claim being delayed or denied. Always double-check that you’ve filled out every mandatory field correctly.

Another mistake often made is the failure to submit itemized paid receipts along with the claim form. Simply stating the amount charged without proper documentation may lead to complications. The receipts serve as proof of your expenses and are vital for the reimbursement process. Make sure you have all the necessary paperwork ready to submit.

Many claimants mistakenly assume that submitting the form electronically means they are excluded from having to sign it. However, a signature is a key requirement to validate your claims. Omitting your signature can automatically result in the rejection of your claim. Take the time to review your form and ensure that you have signed it where necessary.

People also sometimes overlook the timeframe for submitting their claim forms. Claims must be submitted within 12 months of the date of service. Waiting too long can jeopardize your ability to get reimbursed. It is crucial to act promptly and submit your claim as soon as you have the necessary information.

Lastly, another common error involves misunderstanding the specific instructions provided for completing the form. There are guidelines regarding how to calculate and enter the amount charged for each service type. Be attentive to these details. Incorrectly entered amounts can lead to discrepancies and further complications in reimbursement. By taking time to understand and adhere to the instructions, claimants can avoid unnecessary setbacks.

Documents used along the form

When submitting your Blue Vision Claim form, it is crucial to have a well-organized set of documents that facilitate a smooth reimbursement process. Here is a list of documents often required alongside the claim form, each serving a specific purpose to ensure your claim is processed efficiently.

  • Itemized Receipts: You must provide receipts detailing the services and products you received. These documents should specify the exact amounts charged for each service and item, aiding in the verification of your claim.
  • Prescription Information: A copy of the eyeglasses or contact lens prescription from your optometrist or ophthalmologist may be necessary. This document verifies the medical need for the services rendered.
  • Proof of Payment: Bank statements or credit card statements that show payment for the services can help substantiate your claim. These documents confirm that you settled the expenses out-of-pocket.
  • Eligibility Verification: This document confirms your coverage under the vision plan. Check your insurance card, as it typically has the necessary information regarding your policy.
  • Claim Submission Cover Letter: A brief letter summarizing the purpose of your claim can be beneficial. Include your member ID, the date of service, and any other relevant details to expedite the review process.
  • Authorization Form: If required, include a signed authorization form allowing Blue View Vision to obtain information from external sources. This helps in verifying details related to your claim more swiftly.
  • Network Access Exception Form: If you utilized out-of-network services due to a lack of in-network providers, this form justifies your choice. Be prepared to explain why you could not access in-network care.
  • Medical Record Summary: In cases where your claim involves complicated medical details, a summary from your healthcare provider can clarify your situation and support your claim.
  • Previously Submitted Claims: If this claim is related to previous claims, including those documents can prevent confusion and provide context regarding your requested reimbursements.
  • Contact Information Form: A form providing updated contact details aids in ensuring seamless communication regarding your claim. Include phone numbers and email addresses where you can be reached.

Compiling these documents thoughtfully will not only streamline the claims process but also boost your chances of receiving a timely reimbursement. Be proactive and submit everything required to ensure your experience is as smooth as possible.

Similar forms

  • Health Insurance Claim Form: Similar to the Blue Vision Claim form, this document is used to request reimbursement for medical services received from out-of-network providers. Both forms require detailed information including provider details, patient information, and dates of service. Timely submission is also essential, typically within a specified period after the service date.

  • Dental Insurance Claim Form: Like the Blue Vision Claim form, this form serves to document and request reimbursement for dental services rendered by out-of-network providers. It similarly calls for itemized billing details and patient-specific information, while adhering to submission deadlines for proper processing.

  • Out-of-Network Reimbursement Form: This document is specifically tailored for patients seeking reimbursement for services outside their insurance network. Much like the Blue Vision Claim form, it emphasizes the need for itemized receipts and regards the importance of following claims procedures closely to avoid denial.

  • Medicare Claim Form: This form is utilized to claim Medicare benefits for eligible medical services. The process is comparable to the Blue Vision Claim form as both require personal identification and detailed information about the service provider, along with timely submission to avoid denial of coverage.

  • Vision Care Benefits Claim Form: Almost identical in function, this form is directed at vision care services and requests reimbursement for treatments and products. The Blue Vision Claim form shares similarities in required documentation, including service type and charges, highlighting the importance of proper completion and adherence to submission timelines.

Dos and Don'ts

When filling out the Blue Vision Claim form, there are essential steps to follow and common mistakes to avoid. Here’s a list to guide you:

  • Do ensure that you complete the form in full.
  • Do submit your claim within 12 months from the date of service.
  • Do include itemized paid receipts with your claim form.
  • Do double-check all information for accuracy before submission.
  • Do sign the claim form to authorize the processing of your claim.
  • Don't disregard the instructions provided with the claim form.
  • Don't forget to include your personal details such as Member ID and birthdate.
  • Don't use an out-of-network provider without verifying your eligibility for reimbursement.
  • Don't submit the form without the necessary receipts; this may delay your claim.
  • Don't leave any required fields blank, as incomplete information may lead to rejection.

Misconceptions

When it comes to the Blue Vision Claim form, misunderstandings can lead to confusion and delays in the reimbursement process. Here are four common misconceptions and explanations to clarify them:

  • Misconception 1: The claim form can be submitted any time after the service.

    • Many people believe there is no deadline for submitting the claim. However, it’s essential to know that you must submit the claim within 12 months from the date of service. Delayed submissions may result in denial of your claim for reimbursement.

  • Misconception 2: Any receipt can be sent with the claim form.

    • Some individuals think that any receipt will suffice. In reality, you need to include itemized paid receipts specifically showing the charges for services rendered. Incomplete receipts may lead to a rejection of your claim.

  • Misconception 3: Submitting electronically is not necessary.

    • While it may seem convenient to submit by mail, utilizing the online claim form can enhance the efficiency of processing your claim. Electronic submissions allow for faster processing, reducing the wait time for your reimbursement.

  • Misconception 4: You don’t need to sign the claim form.

    • Some may overlook the requirement to sign the form, thinking it’s optional. In fact, your signature certifies the accuracy of the information provided and is mandatory for processing your claim. Without it, your claim may be deemed invalid.

Key takeaways

When filling out and using the Blue Vision Claim form, keep the following key points in mind:

  • Claims must be submitted within 12 months of the service date.
  • Use the online form if you are utilizing electronic assistive devices.
  • Gather itemized paid receipts to accompany your claim submission.
  • Submissions can be made via email, fax, or mail, offering flexibility for your convenience.
  • Ensure all required fields are completed, including patient and subscriber information.
  • Check your vision plan for specific benefits and to avoid unexpected denials.
  • Remember to sign the form, certifying that all provided information is accurate.

Following these steps can help streamline your claim process and ensure you receive any entitled reimbursements efficiently.

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