Fillable Out Of Network Vision Services Claim Form - Aetna Vision printable pdf download

O ut of Network

V ision Services Claim Form

Claim Form Instructions

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 in the

Aetna 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 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 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. 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 patient name and date of service must be included on the

receipt. 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:

Aetna Vision

Attn: OON Claims

P.O. Box 8504

Mason, OH 45040-7111

Please allow at least 14 calendar days to process your claims once received by Aetna 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.

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.

Out Of Network Vision Services Claim Form - Aetna Vision