Eyemed is a medical insurance company that offers coverage for glasses, contacts and other eye-related services. They have a form that you can fill out to see if your service is considered medically necessary. This form can be helpful if you're trying to get coverage for something that's not typically covered by insurance or if you're trying to get reimbursed for a service you've already received. In this blog post, we'll go over what Eyemed considers to be medically necessary and how to fill out the form. We'll also give some real-world examples of when this form might come in handy.
Question | Answer |
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Form Name | Eyemed Medically Necessary Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | eyemed medically necessary contacts, eyemed medically online, eyemed lens claim form, pdf80kb form from illinois state pension plan eye med |
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EyeMed |
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4 0 0 0 Luxot t ica Place |
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Med ica lly Necessa r y Cont a ct Lens |
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Cincinnat i, OH 4 5 0 4 0 |
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Cla im For m |
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Visit us online at w w w .eyem ed .com |
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Pr ovid er Reim b ur sem ent |
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Fax claim form t o 8 6 6 .2 9 3 .73 73 |
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Pa t ient Inf or m a t ion (Req uir ed ) |
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Last Nam e |
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First Nam e |
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Middle Init ial |
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St reet Address |
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Cit y |
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St at e |
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Zip Code |
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Birt h Dat e (MM/ DD/ YYYY ) |
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Telephone Num ber ( w it h area code) |
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Mem ber ID # (if applicable ) |
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Relat ionship t o t he Subscriber |
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Self |
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Child |
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Ot her |
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Sub scr ib er Inf or m a t ion (Req uir ed ) |
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Last Nam e |
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First Nam e |
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Middle Init ial |
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St reet Address |
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Cit y |
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St at e |
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Zip Code |
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Birt h Dat e (MM/ DD/ YYYY ) |
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Telephone Num ber (w it h area code) |
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Vision Plan Nam e |
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Vision Plan/ Group # |
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Dat e of Service (Req uir ed ) (MM/ DD/ YYYY) |
Aut horizat ion # : |
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Med ica lly Necessa r y Cod es (Includ es Cont a ct Lens Eva lua t ion/ Fit a nd Follow a nd Ma t er ia ls) - SUBMIT A S PRIMA RY |
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Check A LL CODES t ha t a p p ly t o f ina l Rx, a s p ub lished in t he EyeMed Pr of essiona l Pr ovid er Ma nua l |
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A nisom et r op ia |
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High A m et r op ia |
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Ker a t oconus |
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Vision Im p r ovem ent |
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9 2 3 10 A N |
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9 2 3 10 HA |
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9 2 0 72 |
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9 2 3 10 VI |
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Select t his if Rx is 3 D in |
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Select t his if Rx exceeds - 10 D or +10 D in |
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Select t his if diagnosis is Kerat oconus. |
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Ker a t oconus is a b sent |
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m eridian pow ers. Check t his |
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m eridian pow ers in eit her eye. |
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Check t his box and t he one below . |
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Select t his for m em bers w hose vision can be |
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box and t he box below . |
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Reim burses up t o $ 70 0 for services and |
Reim burses up t o $ 12 0 0 for services and |
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correct ed by t w o lines on t he visual acuit y chart . |
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Reim burses up t o $ 70 0 for |
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m at erials. |
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m at erials. |
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Reim burses up t o $ 2 5 0 0 for services and |
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services and m at erials. |
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m at erials. |
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ICD- 9 Cod e |
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ICD- 9 Cod e |
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3 6 7.3 1 |
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3 71.6 0 |
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U&C $ |
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U&C |
$ |
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U&C |
$ |
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U&C $ |
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Com p let e Inf or m a t ion Below f or Mem b er s Cover ed b y Ped ia t r ic Vision Benef it s - CA LIFORNIA ONLY |
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Ped ia t r ic A nir id ia |
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Ped ia t r ic A p ha kia |
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9 2 3 10 A I |
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9 2 3 10 A P |
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(CA only) |
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(CA only) |
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Reim burses up t o $ 3 73 0 for |
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Reim burses up t o $ 5 8 0 0 for services and |
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services and m at erials. |
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m at erials. |
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ICD- 9 Cod e |
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ICD- 9 Cod e |
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74 3 .4 5 |
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3 79 .3 1 |
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U&C $ |
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U&C |
$ |
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Req uest f or Ma t er ia l Reim b ur sem ent (Ent er U&C A m ount Cha r ged ) - SUBMIT A S SECONDA RY |
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SO5 0 0 |
$ |
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V2 5 0 0 - V2 5 0 3 |
$ |
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V2 5 2 0 - V2 5 2 3 |
$ |
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V2 5 9 9 |
$ |
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V2 5 10 - V2 5 13 |
$ |
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V2 5 3 0 - V2 5 3 1 |
$ |
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Im p or t a nt Inf or m a t ion |
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W e'll periodically review clinical records t o m ake sure you're correct ly applying t he m edically necessary cont act lens benefit . W e'll be looking t o see t hat t he docum ent ed prescript ion support s t he qualifying condit ion subm it t ed . If t he record doesn't support t his condit ion, w e'll recoup any overpaym ent by w it hholding paym ent on fut ure claim (s) w here law perm it s. As you m ay know , w e can consider any inaccurat e subm ission t o be a false claim . Falsifying inform at ion or filing false claim s can result in disciplinary act ion up t o and including t erm inat ion from our net w ork. If w e believe you've filed a false claim , w e m ight also have t o report it t o regulat ory and law enforcem ent agencies as appropriat e. See ht t p :/ / w w w .eyem ed inf ocus.com / t he- b a sics/ online- p r ovid er - m a nua l for our full Qualit y Assurance process and disciplinary act ions.
Do not file t he claim for m edically necessary cont act lenses elect ronically. Fax claim form t o 8 6 6 .2 9 3 .73 73
Fax a correct ed claim t o 8 6 6 .2 9 3 .73 73 ; m ark t he subm ission "Cor r ect ed Med . Nec. Cont a ct Cla im ."
Pr ovid er Na m e: |
Ta x ID Num b er : |
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Ser vicing loca t ion na m e a nd f ull a d d r ess: |
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Pr ovid er Signa t ur e: |
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Da t e: |
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Ef f ect ive 11/ 14 / 13