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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.
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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)
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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 [email protected]
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)
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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
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o s le n lti
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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
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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) !
. ,
.
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.
855-258-6518 , 0.
, .
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(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
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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 Karte angegebene
Telefonnummer. Alle anderen Personen rufen
bitte die Nummer 855-258-6518 an und warten auf die
Aufforderung, die Taste 0 zu drcken. Geben Sie dem
Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem
Dolmetscher verbinden kann.
Franais (French) Attention: cet avis contient des informations
sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez
entreprendre des dmarches avant certaines chances.
Vous avez le droit d'obtenir gratuitement ces informations et de
l'aide dans votre langue. Les membres doivent
appeler le numro de tlphone figurant l'arrire de leur carte
d'identification. Tous les autres peuvent appeler le
855-258-6518 et, aprs avoir cout le message, appuyer sur le 0
lorsqu'ils seront invits le faire. Lorsqu'un(e)
employ(e) rpondra, indiquez la langue que vous souhaitez et vous
serez mis(e) en relation avec un interprte.
(Korean) : . .
. ID .
855-258-6518 0 .
.
(Navajo)
855-258-6518