Vision / Eye Care Claim Form - CareFirst

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  • Vision/Eye Care Claim Form

    PATIENT AND SUBSCRIBER INFORMATION1. PATIENTS NAME (First, Middle Initial, Last Name) 2. PATIENTS DATE OF BIRTH 3. SUBSCRIBERS NAME (First, Middle Initial, Last Name)

    4. PATIENTS OTHER INSURANCE INFORMATION

    IS PATIENT COVERED UNDER OTHER INSURANCE?

    YES q NO q IF YES, NAME OF INSURANCE CO.

    IS PATIENT COVERED UNDER MEDICARE? YES q NO q

    IF YES, PART A q PART B q NAME OF POLICY HOLDER (INCLUDING MEDICARE)

    INSURANCE OR MEDICARE NUMBER

    5. PATIENTS SEX

    MALE q FEMALE q

    6. SUBSCRIBERS ID NUMBER

    7. RELATIONSHIP TO SUBSCRIBER

    SELF q SPOUSE q CHILD q OTHER q

    8. SUBSCRIBERS GROUP NUMBER OR ENROLLMENT CODE

    9. WAS CONDITION DUE TO:

    WORK? YES q NO q

    AUTO ACCIDENT? YES q NO q

    ANOTHER PARTY AT FAULT? YES q NO q

    IF YES, ATTACH DETAILS

    10. SUBSCRIBERS ADDRESS CHECK IF NEW ADDRESS q

    STREET

    CITY

    STATE ZIP

    11. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND AUTHORIZE THE RELEASE OF ANY AND ALL MEDICAL INFORMATION REQUIRED TO REVIEW AND PROCESS THIS CLAIM. ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

    SIGNATURE OF SUBSCRIBER OR SPOUSE DAYTIME TELEPHONE NO. ( ) DATE

    AUTHORIZATION FOR ASSIGNMENT OF BENEFITS (SEE REVERSE)I, THE UNDERSIGNED, AUTHORIZE AND REQUEST CAREFIRST BLUECROSS BLUESHIELD TO MAKE PAYMENT FOR BENEFITS DUE HEREIN TO:

    12.

    NAME OF PROVIDER PROVIDERS TAX OR SOCIAL SECURITY NUMBER

    SIGNATURE OF SUBSCRIBER OR SPOUSE DATE

    PROVIDER INFORMATION: TYPE OR PRINT: ITEMS 13-36 MUST BE COMPLETED BY THE PROVIDER13. ICD - 9 - CM DIAGNOSIS CODE(S) OR BRIEFLY DESCRIBE CONDITION 14. DATE PRESCRIPTION LENS ORDERED BY PATIENT 15. DATE OF INJURY (Accident or Onset)

    16. WERE NEW LENSES PRESCRIBED?

    YES q NO q

    17. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? IF YES, DATE OF ONSET

    YES q NO q

    18. FOR SERVICES RELATED TO HOSPITALIZATION, DATE HOSPITALIZED

    ADMITTED DISCHARGED

    19. LENSES: Glass q Plastic q Other q

    21. LENSES: Executive q Flattop q Other q

    24. WERE LENSES OVERSIZED? YES q NO q

    25. WERE LENSES TINTED? None q Photogray q Other q

    20. PATIENT RX: SPHERICAL CYLINDRICAL AXIS

    R: L: R: L: R: L:

    22. WAS THIS RX FOR SUNGLASSES? 23. REFERRAL - SEE ITEM 23 ON REVERSE

    26. LAST VISION EXAM DATE 27. CATARACT SURGERY DATE 28. PROVIDER SPECIALTY

    Physician q OD q Optician q

    Exam resulted in referralExam resulted from referralNone of the above

    29. A B C D E F GDATES OF SERVICE

    FIRST LAST

    PLACE OF

    SERVICE

    30

    30

    30

    30

    30

    30

    30

    30

    30

    30

    30

    PROCEDURE CODE

    92004

    92002

    92081

    V2101

    V2201

    V2301

    V2500

    V2502

    V2020

    V2115

    92499

    SERVICES OR SUPPLIES PROVIDED CHARGES FREQ TYPE OF

    SERVICE

    1.

    2.

    3.

    4.

    5.

    6.

    7.

    8.

    9.

    10.

    11.

    12.

    A comprehensive examination and evaluation with initiation of diagnostic and treatment program

    An intermediate examination and evaluation with initiation of diagnostic and treatment program

    Visual Field examination with or without refractionHalf pair, single vision lensHalf pair, bifocal lensHalf pair, trifocal lensContact lenses, PMMA, spherical, per lensContact lenses, PMMA, bifocal, per lensFrames, purchaseLenticular lens, per lensNot Otherwise Classified

    9M09M09M09M09M09M09M09M09M09M09M09M0

    30. PROVIDERS NAME 31. PROVIDERS TAX OR SSN 32. PROVIDERS TELEPHONE NO. 33. TOTAL CHARGE 34. OTHER INS.

    35. PROVIDERS ADDRESS 36. SIGNATURE OF PROVIDER: I certify that the above services and/or supplies were provided by me or under my personal direction

    PD. AMT.

    DATE

    CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association.

  • Instructions

    THIS FORM IS USED TO SUBMIT A CLAIM FOR SERVICES UNDER YOUR HEALTH PLAN. TO AVOID HAVING YOUR CLAIM RETURNED:

    n Prepare a SEPARATE CLAIM FORM for each family member.

    n Complete ALL OF THE INFORMATION REQUESTED in items 1 through 11.

    n Complete item 12 if you PREFER THAT BENEFITS BE PAID TO THE PROVIDER OF SERVICE. CareFirst BlueCross BlueShield reserves the right to make payment directly to the subscriber and to refuse to honor the assignment of any claim to any person or party.

    Please complete Items 4, 6, and 8 as specified below:

    Item 4: If you also have any other health insurance coverage for Vision/Eye Care, complete item 4.

    Item 6: Indicate Identification Number as it appears on your Identification Card, or the subscribers Social Security Number.

    Item 8: Indicate the Group Number from your Identification Card.

    PROVIDER INFORMATION

    The provider is to complete items 13 through 36 as indicated. The following items are to be completed as specified below. If the provider does not complete the reverse side, a completely itemized bill must be attached.

    Item 23: Complete with the name of the provider who referred the patient to you or the name of the provider to whom you referred the patient.

    Item 29D: If the service or supply which you provided is preprinted under 29D, please complete the date of service, the place of service if appropriate, the charge and the frequency. If the service or supply which you provided is not printed under 29D, please complete the blank line under Item 29.

    Item 29D.3: Visual field examination with diagnostic evaluation; with or without refraction; examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent)

    Item 29F: Unless otherwise indicated by the procedural description, the frequency of supplies is important when billing for one or more lenses. Use this to indicate the number of lenses or the frequency of each specified code.

    Item 36: If the claim form is being used in place of an itemized bill, the provider must sign and date the claim in item 36.

    BEFORE SUBMITTING YOUR CLAIM, PLEASE BE SURE THAT:

    1. The subscriber has completed items 111 and item 12, if applicable.

    2. The provider has completed items 1336 or a completely itemized bill is attached.

    3. You have kept copies of the claim for your personal records, if needed.

    Vision/Eye Care Program subscriber claims should be submitted to:

    CareFirst BlueCross BlueShield Mail Administrator P. O. Box 14115 Lexington, KY 40512-4115

    CUT0166-1S (2/18)

  • Notice of Nondiscrimination and Availability of Language Assistance Services

    CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

    CareFirst:

    Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)

    Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages

    If you need these services, please call 855-258-6518.

    If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

    To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

    Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224

    Email Address civilrightscoordinator@carefirst.com

    Telephone Number 410-528-7820 Fax Number 410-505-2011

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

    U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

    REV. (12/17)

  • Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

    and you may need to take action by certain deadlines. You have the right to get this information and assistance in

    your language at no cost. Members should call the phone number on the back of their member identification card.

    All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

    answers, state the language you need and you will be connected to an interpreter.

    (Amharic) -

    855-258-6518 0

    d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti

    gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb

    gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr

    tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

    Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th

    cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn

    c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi

    mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho

    n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c

    kt ni vi mt thng dch vin.

    Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

    insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

    aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

    wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang

    identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

    diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo

    at ikokonekta ka sa isang interpreter.

    Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que

    incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene

    derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al

    nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al

    855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

    responda, indique el idioma que necesita y se le comunicar con un intrprete.

    (Russian) !

    . ,

    .

    . ,

    .

    855-258-6518 , 0.

    , .

  • (Hindi) : - 855-258-6518 0 ,

    s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k

    ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-

    kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa

    I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke

    na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin

    ke ni wuu mu za.

    (Bengali) : 855-258-6518 0

    : (Urdu )

    0 6518-258-855

    : . (Farsi ). .

    .

    . 0 855-258-6518

    .

    : (Arabic) . .

    .

    .0 855-258-6518

    .

    (Traditional Chinese)

    855-258-6518

    0

  • Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d

    mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na

    akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere

    ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo

    ass chr, a ga-ejik g na onye kwa okwu.

    Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

    wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

    das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

    verwenden Sie bitte die auf der Rckseite Ihrer Ka...

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