Blue View Vision SM

Claim submissions
made easy
If you saw an out-of-network eye doctor and you have
out-of-network benefits, your next step is to send a
completed out-of-network claim form. Here’s how:

Online
Click below to complete an electronic claim form.
Go green and get paid faster.

–OR–

By mail
Complete and return the following paperwork.

Access Form

If you will be using electronic assistive devices to

complete the form, please use the online form.
Claim forms must be submitted within 12 months of
the date of service. For complete terms and conditions,
review the claim form.

PDF-1806-RM-646
OUT OF NETWORK/INDEMNITY
Blue View Vision SM

VISION SERVICES CLAIM FORM

Claim Form Instructions

To request reimbursement, please complete and sign
the itemized claim form. Return the completed form
and your itemized paid receipts to:
Email: [email protected] | Fax: 866-293-7373
Mail: Blue View Vision, 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

Vision Plan Name Date of Service† (MM/DD/YYYY)

Vision Plan Group # Subscriber Member ID #

Required
†
continued 1
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Request for Reimbursement

Enter Amount Charged.† Remember to include itemized paid receipts.†

Amount Please Lens Options: Amount

Service Type Lens Type
Charged Check (if purchased) Charged

Exam Single Anti-Reflective

$ $
*92014* *V2100* *V2750*
Refraction Bifocal Polycarbonate
$ $
*92015* *V2200* *V2784*
Frame Trifocal Scratch
$ $
*V2025* *V2300* *V2760*
Contact Lens Progressive Tint
$ $
*S0500* *V2781* *V2745*
Contact Lens Prem Prog UV
$ $
Fitting *92310* *V278126* *V2755*
Lenses Roll and Polish
$ Other $ $
*V2702*

Enter Total Amount Paid as shown on receipt,

$
excluding sales tax†

Required
†
continued 2
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

I hereby understand that without confirmation from Blue View Vision for services
rendered, I may be denied reimbursement for submitted vision care services for
which I am not eligible. 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.

California: For your protection, California law requires the following to appear on this
form: Any person who knowingly presents false or fraudulent information to obtain or
amend insurance coverage or to make a claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.

New York: Any person who knowingly and with intent to defraud any insurance
company or other person files 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 five thousand dollars and the stated value of the claim for
each such violation.

Additional State Fraud Warning Statements listed on the following page.

Member/Guardian/Patient Signature (not a minor)† Date

Required
†
continued 3
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Revision date
State Fraud Warning Statements September 2023

General Fraud Warning: Any person who, with intent to defraud or knowing that
he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud and may be
subject to fines and confinement in prison.

For the states of AL, AK, AZ, AR, CA, CO, DE, DC, FL, GA, HI, ID, IN, KS, KY, LA, MA.
MD, ME, MN, NC, NE, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA
and WV, please refer to the following fraud notices:

Alabama: Any person who knowingly presents a false or fraudulent claim for
payment of loss or benefit or who knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to restitution,
fines or confinement in prison, or any combination thereof.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive
an insurance company files a claim containing false, incomplete, or misleading
information may be prosecuted under state law.

Arizona: For your protection, Arizona law requires the following statement to appear
on this form: Any person who knowingly presents a false or fraudulent claim for
payment of a loss is subject to criminal and civil penalties.

Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowingly
presents a false or fraudulent claim for payment of loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may
be subject to fines and confinement in 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, fines, 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.

Delaware: Any person who knowingly, and with intent to injure, defraud or deceive
any insurer, files a statement of claim containing any false, incomplete or misleading
information is guilty of a felony.

continued 4
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

District of Columbia: WARNING: It is a crime to provide false or misleading

information to an insurer for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a claim was provided by
the applicant.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any
insurer files a statement of claim or an application containing any false, incomplete,
or misleading information is guilty of a felony of the third degree.

Georgia, Vermont: Any person who with intent to defraud or knowing that he/
she is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may be guilty of insurance fraud.

Hawaii: For your protection, Hawaii law requires you to be informed that presenting
a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or
imprisonment, or both.

Idaho: Any person who knowingly, and with intent to defraud or deceive any
insurance company, files a statement of claim containing any false, incomplete,
or misleading information is guilty of a felony.

Indiana: A person who knowingly and with intent to defraud an insurer files a
statement of claim containing any false, incomplete, or misleading information
commits a felony.

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 files 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 files 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.

Maine, Tennessee, 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 may include imprisonment, fines or a denial of
insurance benefits.

continued 5
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Maryland: Any person who knowingly and willfully presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly and willfully presents false
information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.

Massachusetts: Any person who knowingly and with intent to defraud any insurance
company or another person files 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, may be committing a fraudulent
insurance act, which may be a crime and may subject the person to criminal and
civil penalties.

Minnesota: A person who files a claim with intent to defraud or helps commit a
fraud against an insurer is guilty of a crime.

Nebraska: Any person who, with intent to defraud or knowing that he or she
is facilitating a fraud against an insurer, submits an application or files a claim
containing false, incomplete or misleading information is guilty of insurance fraud.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any
insurance company, files a statement of claim containing any false, incomplete or
misleading information is subject to prosecution and punishment for insurance fraud,
as provided in RSA 638:20.

New Jersey: Any person who knowingly files a statement of claim containing any
false or misleading information is subject to criminal and civil penalties.

New Mexico: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.

North Carolina: Any person with the intent to injure, defraud, or deceive an insurer
or insurance claimant is guilty of a crime (Class H felony) which may subject the
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 files a claim containing a false or
deceptive statement is guilty 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.

continued 6
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Oregon: Any person who knowingly, and with intent to defraud any insurance
company or other persons files 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, may be subject to prosecution for
insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance
company or other person files 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 benefit,
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 fine
of not less than five thousand ($5,000) and not more than ten thousand ($10,000),
or a fixed 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 five (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.

Texas: Any person who knowingly presents a false or fraudulent claim for payment
of a loss is guilty of a crime and may be subject to fines and confinement in state
prison.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating
a fraud against an insurer, submits an application or files a claim containing a false or
deceptive statement may have violated state law.

continued 7
OUT OF NETWORK/INDEMNITY 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.

If this applies to you, please complete the following form. If not, please skip
this section.

Based from your home or office location, you have the right to obtain in-network level
of benefits 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. You must submit a claim form to Blue
View Vision for reimbursement.

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 office 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 files a claim containing a false or deceptive statement is guilty of
insurance fraud.

continued 8
OUT OF NETWORK/INDEMNITY VISION SERVICES CLAIM FORM

Check the boxes that apply. I acknowledge that I fit 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 Telephone
Provider’s Name 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.
9