Blue Vision Claim Form – Fill Out and Use This PDF

The Blue Vision Claim Form is designed for individuals who have visited an out-of-network eye doctor and possess out-of-network benefits, facilitating the reimbursement process. Users can submit their claim either online for a quicker process or by mail by completing and returning the necessary paperwork, with a submission deadline of 12 months from the date of service. Click the button below to access the form and complete your submission.

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Blue Vision Claim Form PDF Details

Filing a claim with Blue View VisionSM for out-of-network vision services can be straightforward and beneficial for those who choose to see eye doctors outside their network. Understanding the process and options available—such as submitting your claim online for a faster reimbursement or using the traditional mail-in method—is crucial for a smooth experience. Furthermore, the claim form highlights important details like the submission deadline, which is within 12 months from the date of service, ensuring that patients are aware of the timeframe to avoid missing out on their benefits. The option to use electronic assistive devices for online form completion accommodates all users, promoting accessibility and ease. By staying in-network, members could save significantly, as outlined by the average savings and discounts on additional pairs of glasses, non-prescription sunglasses, and more above the frame allowance. For those needing to go out-of-network due to specific circumstances such as provider availability or location challenges, the form provides guidance on how to obtain in-network benefits under certain conditions, emphasizing the necessity to submit a claim form for reimbursement. Blue View VisionSM's commitment to flexibility and patient assistance is further evidenced by the inclusion of fraud warnings and the requirement for detailed information on the claim form to ensure accuracy and prevent potential fraud, underscoring the importance of transparency and honesty in the claims process.

Question	Answer
Form Name	Blue Vision Claim Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	blue view vision form, blue vision claim, blue vision out network, blue view services

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Blue View VisionSM

Claim submissions made easy

If you saw an out-of-network eye doctor and you have out-of-network benefits, your next step is to send a completed out-of-network claim form. Here’s how:

Online	–OR– By mail
Click below to complete	Complete and
an electronic claim	return the following
form. Go green and	paperwork.
get paid faster.

Access Form

If you will be using electronic assistive devices to complete the form, please use the online form.

Claim forms must be submitted within 12 months of the date of service. For complete terms and conditions, review the claim form.

Stay in-network and save on your next visit*

CHOOSE AN EYE DOCTOR

With thousands of providers across the nation, you can see who you want to see, when and where you want to see them. Whether it’s an independent eye doctor, popular retailer or even online, you have options.

Easily find an eye doctor using the provider locator on your vision benefit member homepage. Search by location, store hours and more — and then schedule your appointment.**

PDF-1806-RM-646

WATCH IT ADD UP

Members who combine an eye exam and new glasses save an average of 72% off retail prices. †

NEVER PAY STICKER PRICE

Receive additional discounts like:††

•40% off additional pairs

•20% off non-prescription sunglasses

•Up to 20% off anything above your frame allowance

FORM FREE

When you stay in-network it’s easy to get an eye exam and get on with your day. There’s no paperwork to fill out or forms to file. Everything is done for you.

*Vision care services frequency may vary. Check your benefits to verify your frequency of services type. **At select in-network providers. †Savings comparison of EyeMed versus care without vision benefits. ††Discounts are not insured benefits and are available at participating in-network providers. Not all discounts are available at all provider locations. Discounts and benefits may vary. Check your benefits.

OUT OF NETWORK/INDEMNITY	Blue View VisionSM
VISION SERVICES CLAIM FORM

Claim Form Instructions

To request reimbursement, please complete and sign the itemized claim form. Return the completed form and your itemized paid receipts to:

Email: oonclaims@eyewearspecialoffers.com | Fax: 866-293-7373

Mail: Blue View Vision, Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111

Patient Last Name†		Patient First Name†		MI

Birth Date (MM/DD/YYYY)† Street Address†

City†			State†	Zip Code†

Patient Member ID #	Relationship to Subscriber
	Self	Dependent

Doctor or Store Name where you received service†

Subscriber Last Name†			Subscriber First Name†			MI

Birth Date (MM/DD/YYYY)	Street Address

City				State	Zip Code

Vision Plan Name		Date of Service† (MM/DD/YYYY)

Vision Plan Group #			Subscriber Member ID #

†Required					continued 1

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Request for Reimbursement

Enter Amount Charged.† Remember to include itemized paid receipts.†

Service Type	Amount	Lens Type	Please	Lens Options:	Amount
Service Type	Charged	Lens Type	Check	(if purchased)	Charged

Exam	$	Single		Anti-Reflective	$
Exam	$	Single		Anti-Reflective	$
92014		V2100		V2750

Refraction	$	Bifocal		Polycarbonate	$
Refraction	$	Bifocal		Polycarbonate	$
92015		V2200		V2784

Frame	$	Trifocal		Scratch	$
Frame		Trifocal		Scratch
V2025		V2300		V2760
V2025		V2300		V2760

Contact Lens	$	Progressive		Tint	$
Contact Lens	$	Progressive		Tint	$
S0500		V2781		V2745

Contact Lens	$	Prem Prog		UV	$
Contact Lens	$	Prem Prog		UV	$
Fitting 92310		V278126		V2755

Lenses	$	Other	$	Roll and Polish	$
Lenses	$	Other	$	Roll and Polish	$
				V2702

Enter Total Amount Paid as shown on receipt,	$
Enter Total Amount Paid as shown on receipt,
excluding sales tax†
excluding sales tax†

I hereby understand that without prior authorization from Blue View Vision Care LLC 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. By signing this claim form, I certify that I have read the applicable claim fraud warnings included with this form, and that all the information furnished by me is true and correct.

Member/Guardian/Patient Signature (not a minor)†		Date

†Required

continued 2

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Network Access Exceptions

We work hard to make sure that you have access to thousands of eye doctors across the nation. Whether it’s due to location or provider availability, you may need to go out-of-network to receive care.

If this applies to you, please complete the following form. If not, please skip this section.

Based from your home or office location, you have the right to obtain in-network level of benefits with an out-of-network provider when: (i) you cannot schedule a visit within two-weeks, (ii) you are unable to locate a participating provider within a 10- mile radius in an urban-suburban area, or (iii) you are unable to locate a participating provider within a 20-mile radius in a rural area. You must submit a claim form to EyeMed for reimbursement.

Caution, this option is not available when you choose to use an out-of-network provider due to (i) your preference, (ii) when your personal schedule does not permit you to schedule an appointment with an available provider in two-weeks, (iii) or you are outside of your home or office location. Any person who, with intent to defraud or knowing that he or she 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.

continued 3

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Check the boxes that apply. I acknowledge that I fit into one or more of the following criteria:

I was unable to schedule a visit within two-weeks with a participating provider.

Please provide the participating provider’s name, location and contact information in which you attempted to schedule an appointment:

	Provider Telephone
Provider’s Name	Number (000-000-0000)
Provider’s Name

Provider Street Address

City

State

Zip Code

I was unable to locate a participating provider within a 10-mile radius in an urban-suburban area.

Please provide the zip code in which you were attempting to locate a provider:

Zip Code

I was unable to locate a participating provider within a 20-mile radius in a rural area.

Please provide the zip code in which you were attempting to locate a provider:

Zip Code

Should you fail to provide the requested information associated with the criteria you selected above, you agree that we can process your claim as

an out-of-network claim.

continued 4

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

State Fraud Warning Statements

Revision date 04/12/18

General Fraud Warning: 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 and may be subject to fines and confinement in prison.

For the states of AL, AK, AZ, AR, CA, CO, DE, DC, FL, GA, HI, ID, IN, KS, KY, LA, MA. MD, ME, MN, NC, NE, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA and WV, please refer to the following fraud notices:

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona: For your protection, Arizona law requires the following statement to appear

on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California: For your protection, California law requires the following to appear on this

form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company

who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

continued 5

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Georgia, Vermont: Any person who with intent to defraud or knowing that he/ she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

Kansas: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud as determined by a court of law.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime.

Maine, Tennessee, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

continued 6

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Nebraska: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing false, incomplete or misleading information is guilty of insurance fraud.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

North Carolina: Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.

continued 7

OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Ohio: 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.

Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon: Any person who knowingly, and with intent to defraud any insurance company or other persons files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, may be subject to prosecution for insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand ($5,000) and not more than ten thousand ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Virginia: Any person who, with the 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 may have violated state law.

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The following areas are what you will have to complete to get the finished PDF form.

part 1 to writing blue vision out network

Please note the crucial details in the Patient, LastName Patient, First, Name BirthDate, MM, DD, YYYY, Street, Address City, State, Zip, Code Patient, Member, ID Relationship, to, Subscriber, Self and Dependent field.

blue vision out network PatientLastName, PatientFirstName, BirthDateMMDDYYYYStreetAddress, City, State, ZipCode, PatientMemberID, RelationshiptoSubscriberSelf, and Dependent blanks to fill

You'll be required certain key information to fill out the Subscriber, LastName Subscriber, First, Name BirthDate, MM, DD, YYYY Street, Address City, State, Zip, Code Vision, Plan, Name Date, of, Service, MM, DD, YYYY Vision, Plan, Group Subscriber, Member, ID and Required box.

blue vision out network SubscriberLastName, SubscriberFirstName, BirthDateMMDDYYYY, StreetAddress, City, State, ZipCode, VisionPlanName, DateofServiceMMDDYYYY, VisionPlanGroup, SubscriberMemberID, and Required fields to fill out

Describe the rights and obligations of the sides within the field Amount, Charged Please, Check Lens, Options, if, purchased Amount, Charged and Other.

blue vision out network AmountCharged, PleaseCheck, LensOptionsifpurchased, AmountCharged, and Other blanks to fill out

Finish the form by reading all of these fields: Date, and Required.

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