Direct Reimbursement Claim Form - Fep Bluevision printable pdf download

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 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

Patient Information

Patient Name:

________________________________________________________

First

Middle Initial

Last

Relationship:

Member

Spouse

Child DOB: ______________

Does the patient have other vision coverage?

Yes

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