Eyemed Medically Necessary Form PDF Details

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.

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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