Out-Of-Network Claim Form

Aetna Vision plans allow members the choice to visit an in-network or out-of-network vision care provider. You only need to complete

this form if you are visiting a provider that is not a participating provider on the Aetna network. Not all plans have out-of-network

benefits, so please consult your member benefits information to ensure coverage of services and/or materials from non-participating

providers.

If you choose an out-of-network provider, please complete the following steps prior to submitting the claim form to Aetna Vision.

Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this

form to Aetna Vision within 1 year from the original date of service at the out-of-network provider’s office.

1. When visiting an out-of-network provider, you are responsible for payment of services and/or materials at the time of service.

Aetna Vision will reimburse you for authorized services according to your plan design.

2. Please complete all sections of this form to ensure proper benefit allocation. Plan information may be found on your benefit ID

Card, or via your human resources department.

3. Aetna Vision will only accept itemized paid receipts that indicate the services provided and the amount charged for each service.

The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider’s letterhead. Attach

itemized paid receipts from your provider to the claim form. If the paid receipt is not in US dollars, please identify the currency in

which the receipt was paid.

4. Please include a copy of your Explanation of Benefits if submitting for a Secondary Insurance Benefit.

5. Sign the claim form below.

Date of Service:

Last four digits of Social Security No.:

Patient Information:

Last Name: ______________________

First Name: ____________________ MI: ______________

Street Address: _________________________________________________________________

City: ______________________

State: _________________

Zip: ______________

Phone:

Birth Date:

Vision Plan Information:

Subscriber Name

Last: _______________________

First: ________________

MI: ______________

Vision Plan Name: ____________________________________________________________

Vision Plan ID: ________________

Subscriber ID: ______________

Request For Reimbursement –Please Enter Amount Charged. Remember to include itemized paid receipts:

Exam:

Frames:

Lenses:

Contact Lenses – (includes fit and follow-up, please submit

$_______

$______

$________

$__________

all contact related charges at the same time)

If lenses were purchased, please check type:

Single

Bifocal

Trifocal

Progressive

I hereby understand that without prior authorization from Aetna Vision 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. I certify that the information furnished by me in support of this claim is true and

correct.

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

Date: _________________

To Fax: 866-293-7373

To Mail:

Aetna Vision

Attn: OON Claims

To Email Claim Form and Receipts:

P.O. Box 8504

Mason, OH 45040-7111

Aetna Vision Special Form

Out-Of-Network Claim Form - Aetna

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