Out-of-network claim submissions made easy
Went out-of-network? No problem, let’s walk through it
completed claim form. You can now submit your form online or by mail:
1.
Online.
Click below to complete an electronic
or
2.
By mail.
Complete and return the
paperwork attached below.
For complete terms and conditions, review the claim form.
Stay in-network and save on your next visit*
Choose an in-network provider
you save more money and get the full value of your
Plus, with Aetna Vision
SM
Preferred Network
providers across the nation, you have access to
lifestyle. You can see who you want to see, when
doctor at aetnavision.com or on the Aetna Vision
Preferred mobile app. Search by location, store
hours, who carries your favorite brand of frames
and more — and then schedule your appointment.
**
Form-free in-network
easy to get an eye exam and get on with
your day. No paperwork. No hassles.
Never pay sticker price in-network
discounts like
†
:
•
prescription glasses
•
•
frame allowance
In-store
and
Online
See the good stu
If you don’t already have the Aetna Vision
SM
Preferred mobile app, be sure to download it from the App Store
or Google Play today.
*
**
At select in-network providers.
†
Discounts available at participating in-network providers. Discounts and
aetna.com
PDF-1802-R-385
Access form
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
Claim Form Instructions
You may be eligible for reimbursement when you visit
an out-of-network provider. To request reimbursement,
please complete and sign this form. Return the
completed form and your itemized paid receipts to:
First American Administrators, Inc.
Attn: OON Claims, P.O. Box 8504, Mason, OH 45040-7111
Patient Last Name
†
Patient First Name
†
MI
Birth Date
†
(MM/DD/YYYY) Street Address
†
City
†
State
†
Zip Code
†
Patient Member ID # Relationship to Subscriber
Self Dependent
Doctor or Store Name where you received service
†
Subscriber Last Name
†
Subscriber First Name
†
MI
Birth Date (MM/DD/YYYY) Street Address
City
State
Zip Code
V
ision Plan Name Date of Service
†
(MM/DD/YYYY)
Vision Plan Group # S
u
b
sc
r
i
ber
M
e
m
ber
I
D
#
†
Required
continued
1
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
Request for Reimbursement
Enter Amount Charged.
†
Remember to include itemized paid receipts.
†
Service Type
Amount
Charged
Exam
*92014*
$
Refraction
*92015*
$
Frame
*V2025*
$
Contact Lens
*S0500*
$
Contact Lens
Fitting *92310*
$
Lenses
$
Lens Type
Please
Check
Single
*V2100*
Bifocal
*V2200*
Trifocal
*V2300*
Progressive
*V 2781*
Prem Prog
*V278126*
Other
$
Lens Options:
(if purchased)
Amount
Charged
Anti-Reective
*V2750*
$
Polycarbonate
*V2784*
$
Scratch
*V2760*
$
Tint
*V2745*
$
UV
*V2755*
$
Roll and Polish
*V2702*
$
Enter Total Amount Paid as shown on receipt,
excluding sales tax
†
$
I hereby authorize any insurance company, organization employer, ophthalmologist,
optometrist and optician to release any information with respect to this claim.
By signing this claim form, I certify that I have read the applicable claim fraud
warnings included with this form, and that all the information furnished by me is
true and correct.
Member/Guardian/Patient Signature (not a minor)
†
Date
†
Required
continued
2
3
continued
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
Network Access Exceptions
We work hard to make sure that you have access to thousands of eye doctors across
the nation. Whether it’s due to location or provider availability, you may need to go
out-of-network to receive care.
Based from your home or ofce location, you have the right to obtain in-network level
of benets with an out-of-network provider when: (i) you cannot schedule a visit
within two-weeks, (ii) you are unable to locate a participating provider within a 10-
mile radius in an urban-suburban area, or (iii) you are unable to locate a participating
provider within a 20-mile radius in a rural area.
Caution, this option is not available when you choose to use an out-of-network
provider due to (i) your preference, (ii) when your personal schedule does not
permit you to schedule an appointment with an available provider in two-weeks, (iii)
or you are outside of your home or ofce location. Any person who, with intent to
defraud or knowing that he or she is facilitating a fraud against an insurer, submits
an application or les a claim containing a false or deceptive statement is guilty of
insurance fraud.
If this applies to you, please complete the following form. If not, please skip
this section.
4
continued
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
Check the boxes that apply. I acknowledge that I t into one or more of the
following criteria:
I was unable to schedule a visit within two weeks with a participating provider.
Please provide the participating provider’s name, location and contact
information in which you attempted to schedule an appointment:
Provider’s Name
Provider Telephone
Number (000-000-0000)
Provider Street Address
City State Zip Code
I was unable to locate a participating provider within a 10-mile radius in an
urban-suburban area.
Please provide the zip code in which you were attempting to locate a provider:
Zip Code
OR
I was unable to locate a participating provider within a 20-mile radius in
a rural area.
Please provide the zip code in which you were attempting to locate a provider:
Zip Code
Should you fail to provide the requested information associated with the
criteria you selected above, you agree that we can process your claim as
an out-of-network claim.
5
continued
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
State Fraud Warning Statements
General Fraud Warning: Any person who knowlingly and with intent to injure, defraud or deceive any insurance company or other person les an
application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution nes
or connement in prison, or any combination thereof. Arkansas, District of Columbia, Rhode Island, West Virginia: Any person who
knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false information in an application for insurance
is guilty of a crime and may be subject to nes and connement in prison. California: For your protection, California law requires the following to
appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
nes and connement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, nes, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to
a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer les a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas: Any person who with
intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or les a claim containing a false or
deceptive statement may be guilty of insurance fraud as determined by a court of law. Kentucky: Any person who knowingly and with intent to
defraud any insurance company or other person les a statement of claim containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime. Louisiana: Any person who
knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false information in an application for insurance
is guilty of a crime and may be subject to nes and connement in prison. Maine and Tennessee: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,
nes or a denial of insurance benets. Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss
or benet or who knowingly and willfully presents false information in an application for insurance is guilt
y of a crime and may be subject to nes
and connement in prison. Missouri: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, nes, denial of insurance and civil damages, as determined by a court of
law. Any person who knowingly and with intent to injure, defraud or deceive an insurance company may be guilty of fraud as determined by a
court of law. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy or knowingly les
a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New York: Any person who knowingly
and with intent to defraud any insurance company or other person les an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the claim for
each such violation. North Carolina: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other
person les an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any material fact material thereto commits a fraudulent insurance act, which may be a crime and subjects such
person to criminal and civil penalties. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or les a claim containing a false or deceptive statement is guilt
y of insurance fraud. Oklahoma: WARNING: Any person
who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any
false, incomplete or misleading information is guilty of a felony. Oregon: Any person who with intent to injure, defraud, or deceive any insurance
company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material thereto may have violate state law. Pennsylvania: Any person who
knowingly and with intent to defraud any insurance company or other person les an application for insurance or statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim
for the payment of a loss or any other benet, or presents more than one claim for the same damage or loss, shall incur a felony and, upon
conviction, shall be sanctioned for each violation with the penalty of a ne of not less than ve thousand ($5,000) and not more than ten thousand
($10,000), or a xed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus
established may be increased to a maximum of ve (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two
(2) years. Texas: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person les an
application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose of
misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject such
person to criminal and civil penalties. Vermont: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company
or other person les an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such
person to criminal and civil penalties. Virginia: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or
other person les an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and
civil penalties. Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, nes, and denial of insurance benets.
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
Aetna complies with applicable Federal civil rights laws and does not discriminate,
exclude or treat people differently based on their race, color, national origin, sex, age,
or disability.
Aetna provides free aids/services to people with disabilities and to people who need
language assistance.
If you need a qualied interpreter, written information in other formats, translation or
other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated
based on a protected class noted above, you can also le a grievance with the Civil
Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA
93779),
1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
You can also le a civil rights complaint with the U.S. Department of Health and
Human Services, Ofce for Civil Rights Complaint Portal, available at http://ocrportal.
hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services,
200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or
at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of
the Aetna group of subsidiary companies, including Aetna Life Insurance Company,
Coventry Health Care plans and their afliates (Aetna).
continued
6
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
7
continued
TTY: 711
To access language services at no cost to you, call the number on your ID card.
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
continued
8
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
continued
9
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
continued
10
OUT-OF-NETWORK VISION SERVICES CLAIM FORM
11
