Form CL00034 "Direct Reimbursement Claim Form - Fep Bluevision" - New York

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Download Form CL00034 "Direct Reimbursement Claim Form - Fep Bluevision" - New York

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FOR INTERNAL USE ONLY
Auth #: ____________________________________
Paid
Denied
Pended
Direct Reimbursement Claim Form
Important Information:
1. Use this form to request reimbursement for services received from providers who do not participate in the FEP BlueVision network.
2. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for
reimbursement.
3. Make sure that all sections are completed, that you and the providers(s) have signed the form, and that all services, charges, and
service dates have been entered. If the form is incomplete, additional information may be required. This may result in a delay of
payment for eligible benefits.
4. Please submit claim reimbursement for each patient on a separate claim form.
5. Please note that the enrollee’s (or employee’s or authorized person’s) signature is required on this form.
6. Mail completed claim form to: FEP BlueVision, P.O. Box 2010, Latham, NY 12110-2010.
7. The completion and submission of this form does not guarantee eligibility for benefits. You may verify your coverage by calling 1-888-550-2583
or visit www.fepblue.org. The patient must pay the provider directly for all services and then submit a claim for reimbursement.
* Your Member Identification No. is the number found on your vision identification card.
Enrollee/Employee Information
(PLEASE PRINT CLEARLY)
Enrollee Name: _____________________________________________________________
Enrollee Identification No.*:______________________
First
Middle Initial
Last
Mailing Address: _____________________________________________________________________________________________________________
Street
City
State
Zip
Business Phone: ________________________________________________
Home Phone: _______________________________________________
Area Code
Area Code
Patient Information
Patient Name:
________________________________________________________
First
Middle Initial
Last
Relationship:
Member
Spouse
Child DOB: ______________
Does the patient have other vision coverage?
Yes
No
Provider Information
Examiner
Dispenser
Name: ________________________________________________________
Name:________________________________________________________
Address: _______________________________________________________
Address: ______________________________________________________
City: __________________________ State: ____ Zip: ________________
City: __________________________ State: ____ Zip: ______________
State License Number: ___________________________________________
State License Number: __________________________________________
Phone Number:__________________________________________________
Phone Number: ________________________________________________
Provider Signature: _____________________________________________
Provider Signature: ____________________________________________
Provider signature is required if this claim form is NOT accompanied by a detailed receipt.
Service
Date of Service
Expense(s) Incurred
1. Eye Examination
(
/
/
)
$
2. Frames
(
/
/
)
$
3. Single Vision Lenses
(
/
/
)
$
4. Bifocal Lenses
(
/
/
)
$
5. Trifocal Lenses
(
/
/
)
$
6. Contact Lenses
(
/
/
)
$
7. Cataract S.V. Lenses
(
/
/
)
$
8. Cataract Bifocal Lenses
(
/
/
)
$
9. Medically Necessary Contact Lenses
(
/
/
)
$
$
Total
Enrollee/Employee Certification
I certify that the information on this form is correct and authorize the Provider to release appropriate information necessary to process this claim to plan provisions. You can be
prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services for someone who is not an eligible
family member or who is no longer in the plan.
Required
_____________________________________________________________
___________________
Enrollee/Employee or authorized person’s signature
Date
cl00034
8/8/13
FOR INTERNAL USE ONLY
Auth #: ____________________________________
Paid
Denied
Pended
Direct Reimbursement Claim Form
Important Information:
1. Use this form to request reimbursement for services received from providers who do not participate in the FEP BlueVision network.
2. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for
reimbursement.
3. Make sure that all sections are completed, that you and the providers(s) have signed the form, and that all services, charges, and
service dates have been entered. If the form is incomplete, additional information may be required. This may result in a delay of
payment for eligible benefits.
4. Please submit claim reimbursement for each patient on a separate claim form.
5. Please note that the enrollee’s (or employee’s or authorized person’s) signature is required on this form.
6. Mail completed claim form to: FEP BlueVision, P.O. Box 2010, Latham, NY 12110-2010.
7. The completion and submission of this form does not guarantee eligibility for benefits. You may verify your coverage by calling 1-888-550-2583
or visit www.fepblue.org. The patient must pay the provider directly for all services and then submit a claim for reimbursement.
* Your Member Identification No. is the number found on your vision identification card.
Enrollee/Employee Information
(PLEASE PRINT CLEARLY)
Enrollee Name: _____________________________________________________________
Enrollee Identification No.*:______________________
First
Middle Initial
Last
Mailing Address: _____________________________________________________________________________________________________________
Street
City
State
Zip
Business Phone: ________________________________________________
Home Phone: _______________________________________________
Area Code
Area Code
Patient Information
Patient Name:
________________________________________________________
First
Middle Initial
Last
Relationship:
Member
Spouse
Child DOB: ______________
Does the patient have other vision coverage?
Yes
No
Provider Information
Examiner
Dispenser
Name: ________________________________________________________
Name:________________________________________________________
Address: _______________________________________________________
Address: ______________________________________________________
City: __________________________ State: ____ Zip: ________________
City: __________________________ State: ____ Zip: ______________
State License Number: ___________________________________________
State License Number: __________________________________________
Phone Number:__________________________________________________
Phone Number: ________________________________________________
Provider Signature: _____________________________________________
Provider Signature: ____________________________________________
Provider signature is required if this claim form is NOT accompanied by a detailed receipt.
Service
Date of Service
Expense(s) Incurred
1. Eye Examination
(
/
/
)
$
2. Frames
(
/
/
)
$
3. Single Vision Lenses
(
/
/
)
$
4. Bifocal Lenses
(
/
/
)
$
5. Trifocal Lenses
(
/
/
)
$
6. Contact Lenses
(
/
/
)
$
7. Cataract S.V. Lenses
(
/
/
)
$
8. Cataract Bifocal Lenses
(
/
/
)
$
9. Medically Necessary Contact Lenses
(
/
/
)
$
$
Total
Enrollee/Employee Certification
I certify that the information on this form is correct and authorize the Provider to release appropriate information necessary to process this claim to plan provisions. You can be
prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEDVIP benefits or try to obtain services for someone who is not an eligible
family member or who is no longer in the plan.
Required
_____________________________________________________________
___________________
Enrollee/Employee or authorized person’s signature
Date
cl00034
8/8/13