Vision Claim Transmittal Form PDF Details

When it comes to vision care claims, ensuring accuracy and completeness in documentation is crucial for a smooth processing experience. The Vision Claim Transmittal form, utilized for submissions to UnitedHealthcare, embodies this principle by guiding both providers and policyholders through a detailed outline of necessary information. Situated at the core of the form are sections dedicated to comprehensive member and patient details, including identification, contact, and insurance information, all designed to streamline the identification and processing of the claim. Noteworthy is the section aimed specifically at vision care providers, mandating the inclusion of a correct patient diagnosis, the date of service, and the precise circling of applicable procedure codes, emphasizing the necessity of precision in health claims submissions. Furthermore, the form addresses scenarios involving accidents, inquiring about their nature and details, an aspect critical for claims tied to specific incidents. It also navigates through the intricacies of dealing with other insurance carriers that may cover the patient, requesting detailed information to ascertain coordination of benefits. Insightfully, the form provides a designated area for providers to list services rendered alongside their associated charges, which plays a pivotal role in determining the claim amount. Significantly, it features an option for the assignment of benefits, which, when opted into, allows for direct payment to service providers, simplifying the reimbursement process. By meticulously filling out this form and ensuring no supplementary documents such as receipts or bills are attached upon submission, claimants enhance the efficiency of the adjudication process, thereby fostering a smoother path to claim resolution.

QuestionAnswer
Form NameVision Claim Transmittal Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesuhc vision claim form, united healthcare reimbursement form vision, united healthcare vision out of network claim form, united healthcare vision reimbursement form

Form Preview Example

VISION CLAIM TRANSMITTAL

Claim Address:

UnitedHealthcare

PO Box 740800 Atlanta, GA 30374-0800

Employer Name: North Jersey Health Insurance Fund

Group (Policy) Number: 705996

Vision Care Providers – please make sure you have indicated the patient’s diagnosis, date of service, and circled the appropriate procedure codes in Section E prior to submitting this claim.

A.MEMBER/EMPLOYEE INFORMATION (Please include your member ID on all documentation):

 

Member # (SSN)

 

 

Last

 

 

 

 

Name:

 

Home Address

 

 

 

 

 

B. PATIENT INFORMATION:

 

 

Last Name:

 

 

 

First Name:

 

 

 

 

 

 

Sex M

F

Relationship to Member:

 

 

 

 

 

 

City

 

 

First

 

 

 

MI:

 

 

Name:

 

 

 

 

 

 

 

 

State

 

Zip

 

 

 

 

 

 

 

Code:

 

 

 

MI:

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

Full Time Student

 

School Name:

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

C. ACCIDENT INFORMATION:

Work Accident? Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How did the accident occur:

Auto Accident? Yes

No

Date Accident Occurred:

//

D.OTHER INSURANCE Is the patient covered

by another insurance plan? Yes

No

If yes, please complete the following:

Name of person

 

Date of Birth:

 

Carrying other insurance:

 

/

/

SSN #:

Name of the Other

 

 

Insurance Carrier

 

Policy Number:

Employer Name:

 

 

 

 

 

E. THIS SECTION TO BE COMPLETED BY PROVIDER

 

 

 

 

 

 

 

 

 

 

PLEASE CHECK APPROPRIATE

BOXES AND INDICATE APPLICABLE CHARGES:

 

 

 

E

Diagnosis: V720

 

 

 

 

 

L

Date of Purchase:________________________________________

 

 

 

 

 

Single Vision

V2101

 

$_____________________

x

Date of Exam: ____ ___________________________

 

 

e

 

 

 

Bifocals

 

V2200

 

$_____________________

a

New Patient

92002

$_______________

 

 

n

 

 

 

 

Trifocals

 

V2300

 

$_____________________

m

 

92004

$_______________

 

 

s

 

 

 

 

 

 

Lenticular

V2121

 

$_________________

s

Established Patient

92012

$_______________

 

 

e

 

 

 

 

 

 

 

 

 

 

 

92014

$_______________

 

 

s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refraction

92015

$_______________

 

 

 

 

 

 

 

 

 

 

 

92310

$____________ _

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

Date of Purchase: ____________________________________

 

C

Date of Purchase:_________________________________________

Standard

V2020

$______________

 

PMMA

V2500

 

$_____________________

r-

 

o

L

 

Deluxe

V2025

$______________

 

Gas Permeable

V2510

 

 

$_____________________

 

n

e

 

 

a

 

 

 

 

 

Hydrophilic

V2520

 

 

$_____________________

 

 

 

 

 

t

n

 

 

m

 

 

 

 

 

 

 

 

 

 

 

 

Scleral

V2530

 

$___________________ _

 

 

 

 

 

a

s

 

e

 

 

 

 

 

 

 

 

 

 

 

c

e

 

 

 

 

 

 

s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

t

s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description:

 

 

 

 

 

 

 

 

 

 

 

 

Total Charges

 

 

$

 

 

 

Amount Paid by the Employee

$

 

Name of Provider who Performed the Services:

 

 

 

 

Phone (Area Code):

 

 

Address:

 

 

 

 

 

 

 

City-State-Zip Code:

 

 

Provider’s Signature:

 

 

 

 

 

Tax ID

 

 

 

Must be Furnished

 

 

 

 

 

 

 

No.:_____________________________

 

 

Date:

 

Degree/Title:

 

 

Employee ID No.: _____________________

Under Authority of

 

 

 

 

 

 

 

 

 

 

 

 

 

Law

F. ASSIGNMENT OF BENEFITS

Please sign below only if you want UnitedHealthcare to pay benefits directly to the provider of vision service:

Patient Signature:

Member Signature:

Date:

 

 

 

NOTE: Please do not attach any receipts or bills to this form. Make sure form is completely filled out and mail only this form to the above address.

How to Edit Vision Claim Transmittal Form Online for Free

It really is not hard to prepare the united healthcare vision claim form. Our editor was created to be enable you to fill in any document swiftly. These are the four steps to take:

Step 1: Hit the "Get Form Now" button to get started on.

Step 2: The file editing page is now open. Include text or update present details.

The PDF template you plan to fill out will consist of the next sections:

part 1 to writing unitedhealthcare vision reimbursement form

You have to enter the crucial information in the E THIS SECTION TO BE COMPLETED BY, Date of Purchase L Single Vision V, Lenticular V, Date of Purchase F Standard V r, Date of Purchase C PMMA V o L Gas, Description Total Charges Amount, Phone Area Code CityStateZip Code, Date, DegreeTitle, F ASSIGNMENT OF BENEFITS Please, Member Signature, Date, Tax ID No Employee ID No, Must be Furnished, and Under Authority of Law area.

stage 2 to filling out unitedhealthcare vision reimbursement form

Step 3: Press "Done". You can now export your PDF document.

Step 4: To prevent yourself from possible upcoming complications, please be sure to have as much as a pair of copies of each and every file.

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