--- type: document title: Humana Vision Claim Form (1) file: ../Humana Vision Claim Form (1).pdf tags: - Russell_County - Documents docDate: null contentType: application/pdf contentLength: 692031 sha256sum: d98b421bf4bfdb1c732027cb62e0a207d63dffd3e5ccae8dac3a8c32a8031a9c sha1sum: f1bae8753b638a0f3e681c04d04f8fa2837f4ecd --- Out of Network HUMANA. ion Services Claim Form Claim Form Instructions Most HumanaVision plans allow members the choice to visit an in-network or out-of-network vision care provider. You only need to complete this form if you are visiting a provider that is not a participating provider in the Humana network. Not all plans have out-of-network benefits, so please consult your member benefits information to ensure coverage of services and/or materials from non-participating providers. If you choose an out-of-network provider, please complete the following steps prior to submitting the claim form to Humana. Any missing or incomplete information may result in delay of payment or the form being returned. Please complete and send this form to Humana within one (1) year from the original date of service at the out-of-network provider's office. 1. When visiting an out-of-network provider, you are responsible for payment of services and/or materials at the time of service. Humana will reimburse you for authorized services according to your plan design 2. Please complete all sections of this form to ensure proper benefit allocation. Plan information may be found on your benefit ID Card or via your human resources department. 3. Humana will only accept itemized paid receipts that indicate the services provided and the amount charged for each service. The services must be paid in full in order to receive benefits. Handwritten receipts must be on the provider's letterhead. Attach itemized paid receipts from your provider to the claim form. If the paid receipt is not in US dollars, please identify the currency in which the receipt was paid Please include a copy of your Explanation of Benefits if submitting for a Secondary Insurance Benefit. Sign the claim form below. Reimbursements will be mailed to the stored mailing address in the Humana membership system. If you recently moved or changed your address, please contact the Call Center to update your information. Pan Return the completed form and your itemized paid receipts to: Humana Vision Care Plan Attn: OON Claims P.O. Box 14311 Lexington, KY 40512-4311 Please allow at least 14 calendar days to process your claims once received by Humana. Your claim will be processed in the order it is received. A check and/or explanation of benefits will be mailed within seven (7) calendar days of the date your claim is processed Inquiries regarding your submitted claim should be made to the Customer Service number printed on the back of your benefit identification card. Out of Network HUMANA. Vision Services Claim Form Patient Information (Required) Last Name CIO0UOUOOOOOO OOOO QDDOIDODIOID OI) |) Street Address City State Zip Code Birth Date (MM/DD/YYYY) Telephone Number QI) -OD)-OD) DIDI) - OD -CC Member ID # Relationship to the Subscriber Self 1] Spouse[] Child2] Other Subscriber Information (Required) GCE COC First Name Middle Initial OULD | Street Address City State | Zip Code Birth Date (MM/DD/YYYY) Telephone Number LIL]- i DUO DUD -D00- OO) Vision Plan Name Vision Plan/Group ID # Subscriber ID # Date of Service (Required) (MM/DD/¥YYY) DO-O0)-O00O Request For Reimbursement —Please Enter Amount Charged. Remember to include copies of itemized expenses: Exam Frame Lenses 8 8 s Iflenses were purchased, please check type: L] Single LJ Bifocal [] Trifocal [] Progressive Contact Lenses - (please submit all contact related s charges at the same time) Thereby understand that without prior authorization from Humana for services rendered, I may be denied reimbursement for submitted vision care services for which I am not eligible. I hereby authorize any insurance company, organization employer, ophthalmologist, optometrist, and optician to release any information with respect to this claim. I certify that the information furnished by me in support of this claim is true and correct Member/Guardian/Patient Signature (not a minor) Date: Humana VCP Gen Pop Out of Network HUMANA. Vision Services Claim Form FRAUD WARNING STATEMENTS: Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company ‘may be prosecuted unde state law. Arizona: For your protection Arizona law requires the following statement to appear on this form, Any person who knowingly presents a false or fraudulent claim for ‘payment ofa loss is subject to eriminal and evi penalties. Arkansas: Any person who knowingly presents a fae or faudulent claim for payment ofa loss or benefit or knowingly presents fase information in an application for insurance s guilty of a crime and may be subject to ines and confinement in prison, California: For your protection Catifomia la require the following to appear on this form: Any person who knowingly presents fuse or fraudulent claim for the payment ‘of a loss is guilty ofa crime and may be subject to fines and confinement in state prison, Colorado: Its unlawful to knowingly provide fale, incomplete, or misleading facts or information to an insurance company fr the purpose of defiauding or attempting 10