Out Of Network Vision Services Claim Form printable pdf download

Claim Form Instructions

Most Blue View Vision Care 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 in the Blue View Vision 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 Blue View Vision. Any missing or incomplete information may result in delay of payment or

the form being returned. Please complete and send this form to Blue View Vision within one (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.

Blue View 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. Blue View 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. Sign the claim form below.

Return the completed form and your itemized paid receipts to:

Mail To:

Blue View Vision

Attn: OON Claims

P.O. Box 8504

Mason, OH 45040-7111

Fax To:

866-293-7373

Email To:

Please allow at least 14 calendar days to process your claims once received by Blue View Vision.

Your claim will be processed in the order it is received. A check and/or explanation of benefits will be

mailed within seven (7) calendar days of the date your claim is processed.

Inquiries regarding your submitted claim should be made to the Customer Service number printed on the

back of your benefit identification card.

Out Of Network Vision Services Claim Form