Medically Necessary Contact Lens Claim Form
This file contains the EyeMed Medically Necessary Contact Lens Claim Form. It provides fields for patient and subscriber information, medically necessary codes, and reimbursement details. It also includes instructions for completing and submitting the form.
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How do I fill this out?
Filling out the Medically Necessary Contact Lens Claim Form is straightforward. Start by entering the required patient information, followed by the subscriber information. Ensure all necessary codes and reimbursement details are accurately specified.
How to fill out the Medically Necessary Contact Lens Claim Form?
1
Enter patient information.
2
Enter subscriber information.
3
Select applicable medically necessary codes.
4
Provide reimbursement details.
5
Submit the completed form as instructed.
Who needs the Medically Necessary Contact Lens Claim Form?
1
Patients needing a medically necessary contact lens benefit.
2
Subscribers responsible for the patient's vision plan.
3
Healthcare providers seeking reimbursement for contact lens services.
4
Members covered by pediatric vision benefits in California.
5
Administrators verifying the accuracy of claims and codes.
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What are the instructions for submitting this form?
Submit the completed form via fax to 866.293.7373. Ensure all required information and codes are accurately filled in before submission. Mark corrected claims as 'Corrected Med. Nec. Contact Claim' and fax to the same number. For more details, visit EyeMed's provider manual online.
What are the important dates for this form in 2024 and 2025?
There are no specific dates mentioned for 2024 and 2025 regarding this form.
What is the purpose of this form?
The Medically Necessary Contact Lens Claim Form is designed to facilitate the reimbursement process for contact lenses deemed medically necessary. This form ensures that both patient and subscriber information is accurately captured and verified. By using this form, patients and providers can efficiently claim the benefits associated with medically necessary contact lenses.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for last name, first name, middle initial, address, city, state, zip code, birth date, and telephone number.
- 2. Subscriber Information: Includes fields for last name, first name, relationship to the subscriber, middle initial, address, city, state, zip code, birth date, telephone number, vision plan name, vision plan/group number, and date of service.
- 3. Medically Necessary Codes: Fields to select applicable codes such as Anisometropia, High Ametropia, Keratoconus, and Vision Improvement, including ICD-9 codes and U&C amounts.
- 4. Pediatric Vision Benefits: Fields specific to California residents for pediatric aniridia and pediatric aphakia codes, with ICD-9 codes and U&C amounts.
- 5. Request for Material Reimbursement: Fields to enter U&C amounts for various codes such as SO500, V2500-V2503, V2520-V2523, V2599, V2510-V2513, and V2530-V2531.
- 6. Provider Information: Includes fields for provider name, tax ID number, servicing location name and address, provider signature, and date.
What happens if I fail to submit this form?
Failure to submit the form may result in delayed or denied reimbursement.
- Non-reimbursement: Failure to submit the form results in no reimbursement for medically necessary contact lenses.
- Future Payment Withholding: Future payments may be withheld until the appropriate documentation is provided.
How do I know when to use this form?
- 1. Medically Necessary Contact Lenses: When contact lenses are required for medical reasons such as Anisometropia, High Ametropia, Keratoconus, or Vision Improvement.
- 2. Pediatric Vision Benefits: Specifically for California residents for conditions like pediatric aniridia and pediatric aphakia.
- 3. Provider Reimbursement: When healthcare providers seek reimbursement for contact lens services.
Frequently Asked Question
How do I fill out the Medically Necessary Contact Lens Claim Form?
You can fill out the form by entering the required patient and subscriber information, selecting applicable medically necessary codes, and providing reimbursement details.
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You can sign the form using our signature tool to add your signature to the designated area.
How can I share the completed form?
You can share the completed form via email or download it and share through your preferred method.
What information is required to fill out the form?
The form requires patient information, subscriber information, applicable medically necessary codes, and reimbursement details.
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Yes, you can save your edits before downloading the finalized document.
What are medically necessary contact lens codes?
These codes specify the medical necessity for contact lenses, such as anisometropia, high ametropia, keratoconus, and vision improvement.
How do I know if I'm eligible for reimbursement?
Check the applicable medically necessary codes and reimbursement details specified on the form.
What should I do if I make an error on the form?
If you make an error, submit a corrected claim marked 'Corrected Med. Nec. Contact Claim'.
Where do I submit the completed form?
The form can be submitted via fax to 866.293.7373 or as instructed in the submission section of the form.
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