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Vision Claim Transmittal Form – Fill Out and Use

A Vision Claim Transmittal Form is a document that informs your vision insurance provider of the procedures you have undergone and any office charges.

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United Healthcare Vision Out Of Network Claim Form Details

The Vision Claim Transmittal Form is a government-provided form used to submit a claim for reimbursement of vision care services. The form can be used to request reimbursement for costs incurred for both medical and optical services, including eyeglasses, contact lenses, and eye surgery. The form must be filled out in full and include all required documentation before it can be processed. Reimbursement amounts are based on the type of service provided and the patient's current insurance coverage. For more information on how to submit a Vision Claim Transmittal Form, please visit our website or contact us toll-free at 1-800-MEDICARE (1-800-633-4227).

The table offers details about the vision claim transmittal form. It's a good idea that you read this information before you begin filling out the file.

Question	Answer
Form Name	Vision Claim Transmittal Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	united healthcare vision claim form, united healthcare vision reimbursement form, united healthcare reimbursement form vision, uhc vision out of network claim form

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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:
B. PATIENT INFORMATION:
Last Name:				First Name:

Sex M	F	Relationship to Member:

City

	First					MI:
	Name:
			State			Zip
						Code:
		MI:			Date of Birth:
		MI:			Date of Birth:

Full Time Student				School Name:
Yes		No

C. ACCIDENT INFORMATION:

Work Accident? Yes				No
Work Accident? Yes				No

How did the accident occur:

Auto Accident? Yes

Date Accident Occurred:

D.OTHER INSURANCE Is the patient covered

by another insurance plan? Yes

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:

Diagnosis: V720

Date of Purchase:________________________________________

Single Vision

V2101

$_____________________

Date of Exam: ____ ___________________________

Bifocals

V2200

$_____________________

New Patient

92002

$_______________

Trifocals

V2300

$_____________________

92004

$_______________

Lenticular

V2121

$_________________

Established Patient

92012

$_______________

92014

$_______________

Refraction

92015

$_______________

92310

$____________ _

Date of Purchase: ____________________________________

Date of Purchase:_________________________________________

Standard

V2020

$______________

PMMA

V2500

$_____________________

Deluxe

V2025

$______________

Gas Permeable

V2510

$_____________________

Hydrophilic

V2520

$_____________________

Scleral

V2530

$___________________ _

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.

Vision Claim Transmittal Form – Fill Out and Use

United Healthcare Vision Out Of Network Claim Form Details

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