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)

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(Amharic) -

855-258-6518 0

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(Hindi) : - 855-258-6518 0 ,

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(Bengali) : 855-258-6518 0

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0 6518-258-855

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: (Arabic) . .

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(Traditional Chinese)

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0

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