Eyemed Medically Necessary Form PDF Details

For individuals with specific eye conditions, the accuracy and care in selecting the correct contact lenses are not just a matter of comfort, but a necessity. The EyeMed Medically Necessary Contact Lens Claim Form serves as a critical tool in ensuring these patients receive the medically necessary contact lenses prescribed by their eye care professionals. Centrally located at the Luxottica Place in Cincinnati, OH, this form is designed for eye care providers to claim reimbursement for services rendered and materials provided to patients under specific medical conditions such as Anisometropia, High Ametropia, and Keratoconus, among others. The form outlines detailed patient and subscriber information, the required medical necessity codes that justify the use of such lenses, and the associated reimbursement caps for these services and materials. Additionally, it contains specific sections for pediatric patients within California, reflecting unique requirements for this group. Important information on the submission process highlights the strict adherence to proper documentation and the potential consequences of submitting inaccurate claims, underscoring the importance of precision in every step of the claim process. With the convenient option to fax the completed form, EyeMed simplifies the administrative work for providers while focusing on the broader goal of affording patients the vision correction they medically require.

QuestionAnswer
Form NameEyemed Medically Necessary Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameseyemed medically necessary contacts, eyemed medically online, eyemed lens claim form, pdf80kb form from illinois state pension plan eye med

Form Preview Example

 

EyeMed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 0 0 0 Luxot t ica Place

 

 

 

 

Med ica lly Necessa r y Cont a ct Lens

 

 

 

 

 

 

 

 

 

 

Cincinnat i, OH 4 5 0 4 0

 

 

 

 

 

 

Cla im For m

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Visit us online at w w w .eyem ed .com

 

 

 

Pr ovid er Reim b ur sem ent

 

 

 

 

 

 

 

 

 

 

Fax claim form t o 8 6 6 .2 9 3 .73 73

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pa t ient Inf or m a t ion (Req uir ed )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Nam e

 

 

 

 

 

 

 

 

First Nam e

 

 

 

 

 

 

 

Middle Init ial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

St reet Address

 

 

 

 

 

 

 

Cit y

 

 

 

 

 

St at e

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birt h Dat e (MM/ DD/ YYYY )

 

 

 

 

 

 

 

Telephone Num ber ( w it h area code)

 

 

 

 

 

 

 

 

 

-

-

 

 

 

 

 

 

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mem ber ID # (if applicable )

 

 

 

 

 

 

 

Relat ionship t o t he Subscriber

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

 

Spouse

 

 

 

 

Child

 

 

Ot her

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sub scr ib er Inf or m a t ion (Req uir ed )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Nam e

 

 

 

 

 

 

 

 

First Nam e

 

 

 

 

 

 

 

Middle Init ial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

St reet Address

 

 

 

 

 

 

 

Cit y

 

 

 

 

 

St at e

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birt h Dat e (MM/ DD/ YYYY )

 

 

 

 

 

 

 

Telephone Num ber (w it h area code)

 

 

 

 

 

 

 

 

 

-

 

-

 

 

 

 

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision Plan Nam e

 

 

 

 

 

 

 

Vision Plan/ Group #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dat e of Service (Req uir ed ) (MM/ DD/ YYYY)

Aut horizat ion # :

 

 

 

 

 

 

 

 

 

 

-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

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

 

 

 

A nisom et r op ia

 

 

 

High A m et r op ia

 

 

 

Ker a t oconus

 

 

 

 

 

Vision Im p r ovem ent

 

 

 

9 2 3 10 A N

 

 

 

 

9 2 3 10 HA

 

 

9 2 0 72

 

 

 

 

 

 

 

 

 

9 2 3 10 VI

 

Select t his if Rx is 3 D in

 

 

Select t his if Rx exceeds - 10 D or +10 D in

 

Select t his if diagnosis is Kerat oconus.

 

 

 

 

Ker a t oconus is a b sent

 

m eridian pow ers. Check t his

 

 

 

m eridian pow ers in eit her eye.

 

Check t his box and t he one below .

 

 

Select t his for m em bers w hose vision can be

 

box and t he box below .

 

 

Reim burses up t o $ 70 0 for services and

Reim burses up t o $ 12 0 0 for services and

 

correct ed by t w o lines on t he visual acuit y chart .

 

Reim burses up t o $ 70 0 for

 

 

 

 

m at erials.

 

 

 

m at erials.

 

 

 

Reim burses up t o $ 2 5 0 0 for services and

 

services and m at erials.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

m at erials.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD- 9 Cod e

 

 

 

 

 

 

 

 

 

 

ICD- 9 Cod e

 

 

 

 

 

 

 

 

 

 

 

 

3 6 7.3 1

 

 

 

 

 

 

 

 

 

3 71.6 0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U&C $

 

 

U&C

$

 

 

 

U&C

$

 

 

 

 

 

 

U&C $

 

 

 

 

 

 

 

 

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

 

 

 

Ped ia t r ic A nir id ia

 

 

 

Ped ia t r ic A p ha kia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9 2 3 10 A I

 

 

 

 

9 2 3 10 A P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(CA only)

 

 

 

 

(CA only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reim burses up t o $ 3 73 0 for

 

 

Reim burses up t o $ 5 8 0 0 for services and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

services and m at erials.

 

 

 

 

m at erials.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD- 9 Cod e

 

 

 

 

ICD- 9 Cod e

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

74 3 .4 5

 

 

 

3 79 .3 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U&C $

 

 

U&C

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

SO5 0 0

$

 

 

 

 

 

 

V2 5 0 0 - V2 5 0 3

$

 

 

 

 

 

 

V2 5 2 0 - V2 5 2 3

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V2 5 9 9

$

 

 

 

 

 

 

V2 5 10 - V2 5 13

$

 

 

 

 

 

 

V2 5 3 0 - V2 5 3 1

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Im p or t a nt Inf or m a t ion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 :

 

 

 

Ser vicing loca t ion na m e a nd f ull a d d r ess:

 

 

 

 

 

Pr ovid er Signa t ur e:

 

Da t e:

 

 

 

Ef f ect ive 11/ 14 / 13

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