The EyeMed medically necessary contacts claim form is the paperwork you submit when your eye doctor has determined that standard glasses can’t adequately correct your vision and specialty contact lenses are the only effective treatment. Which version you use depends on your provider: in-network providers file a dedicated medically necessary form on your behalf, while members who paid an out-of-network provider file EyeMed’s Out-of-Network Vision Services Claim Form for reimbursement.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form2EyeMed. Out of Network Vision Claim Form Expect roughly 14 calendar days for a decision after EyeMed receives a clean submission.3EyeMed Vision Care. Verizon Vision Services Claim Form
Which Form You Actually Need
If you saw an in-network EyeMed provider, the office handles the filing. They complete the medically necessary contact lens claim form, which carries clinical codes and a provider signature, and send it to EyeMed directly.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form Your job is to make sure they have your current ID information and the right diagnosis documented.
If you went to an out-of-network provider and paid out of pocket, you file for reimbursement yourself using EyeMed’s Out-of-Network Vision Services Claim Form. The PDF is available through the EyeMed member portal and the online claims page at eyemedonline.com.2EyeMed. Out of Network Vision Claim Form You can also call EyeMed’s Customer Care Center at 1-888-485-5174 to have a form mailed to you.4State of Colorado. VPD for Insured
Most EyeMed plans do not require pre-authorization for medically necessary contacts; the provider establishes medical necessity at the exam and the claim follows.5Washington State Health Care Authority. PEBB EyeMed Preauthorization Requirements Plan details vary by employer group, though, so confirm with the number on your ID card before scheduling an expensive fitting.
Conditions and Codes That Qualify
EyeMed covers medically necessary lenses only when specific clinical thresholds are met. The qualifying categories and the codes your provider selects on the form are:
- Keratoconus (code 92072): the cornea thins and bulges into a cone, and vision in the affected eye cannot be corrected to 20/25 with standard spectacle lenses.5Washington State Health Care Authority. PEBB EyeMed Preauthorization Requirements
- High ametropia (code 92310HA): a prescription exceeding -10D or +10D in meridian powers in either eye.5Washington State Health Care Authority. PEBB EyeMed Preauthorization Requirements
- Anisometropia (code 92310AN): a refractive power difference of 3 diopters or more between the two eyes.5Washington State Health Care Authority. PEBB EyeMed Preauthorization Requirements
- Vision improvement (code 92310VI): for patients without keratoconus whose contact lenses improve vision by at least two lines on the acuity chart compared with best-corrected glasses.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form
Other situations such as corneal trauma, post-surgical irregular astigmatism, and severe dry eye requiring scleral lenses may also qualify depending on your plan. Your provider selects the category code; a mismatch between the diagnosis in the chart and the code on the form is the single most common cause of denials and clawbacks.
Gather This Before You Fill Anything In
Missing one item is the fastest way to have a claim bounced back.
Member Information
You need the subscriber’s full legal name, date of birth, EyeMed member ID, and group or plan number.6EyeMed Vision Care. Out-of-Network Vision Services Claim Form If the patient is a dependent, add the patient’s name, date of birth, and relationship to the subscriber. Include a current mailing address for correspondence and the reimbursement check.
Provider Information
The form requires the full name and address of the doctor or store, the provider’s federal Tax Identification Number, and, on the in-network medically necessary form, the provider’s signature and date of service.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form
An Itemized, Paid Receipt
A credit card slip showing a total will not do. The receipt must list each service separately with its individual charge and show that the balance was paid in full. EyeMed will not reimburse for services that remain unpaid.3EyeMed Vision Care. Verizon Vision Services Claim Form A handwritten receipt must be on the provider’s letterhead. If services were paid in a foreign currency, note the currency on the receipt.
Ask your provider for the diagnosis and procedure codes before you leave the office. The ICD-10 code identifies the condition, for example H52.31 for anisometropia or a subcode under H18.6 for keratoconus (H18.60 unspecified, H18.61 stable, H18.62 unstable). HCPCS codes identify the lens type, such as V2510 for a gas permeable lens or V2520 for a hydrophilic lens. Chasing codes down later wastes time.
Filling In the Form
Complete every field legibly, and if you’re working on the PDF, type the entries rather than printing and handwriting. Names, dates, and ID numbers must match exactly what’s on your EyeMed card and the provider’s receipt. A minor mismatch between the patient name on your card and the receipt can trigger a rejection.
On the out-of-network form, enter the total amount charged and the total you actually paid (excluding sales tax) in the designated fields, then sign and date.6EyeMed Vision Care. Out-of-Network Vision Services Claim Form A parent or guardian signs for a minor. On the provider-filed medically necessary form, the provider selects the qualifying condition code and enters the usual and customary amount for fitting, follow-up visits, and materials together.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form
How to Submit
The right channel depends on who’s filing.
Member out-of-network claims go to:
First American Administrators, Inc.
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-71116EyeMed Vision Care. Out-of-Network Vision Services Claim Form
Keep copies of everything you send.
Online
At eyemedonline.com, enter your email and EyeMed sends a submission link that stays active for 24 hours.2EyeMed. Out of Network Vision Claim Form Upload a scanned PDF of the completed form and receipts through that link.
Some plans allow a completed form and scanned receipts to be emailed to oonclaims@eyemed.com.4State of Colorado. VPD for Insured Not every employer group has it enabled, so confirm before you send.
Fax
For the provider-submitted medically necessary form, fax to 866-293-7373. Some plan documents specifically instruct providers to use fax rather than electronic submission for these claims.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form
Deadlines and What Happens Next
You have 15 months from the date of service to submit a claim.6EyeMed Vision Care. Out-of-Network Vision Services Claim Form Miss it and EyeMed will not process the claim regardless of how strong your documentation is.
Allow at least 14 calendar days for processing after receipt.3EyeMed Vision Care. Verizon Vision Services Claim Form You can track status in the EyeMed member portal under your claims history, and any request for additional clinical notes will appear there or arrive by mail. Approved claims pay out as a reimbursement check or a direct credit depending on plan structure, with the amount tied to your plan’s reimbursement schedule for the specific qualifying condition. Your Explanation of Benefits breaks down what was covered and any remaining balance.
Correcting a Submitted Claim
If you selected the wrong qualifying condition or made another error after submission, fax a corrected version to 866-293-7373 marked “Corrected Med. Nec. Contact Claim” so it isn’t processed as a duplicate.1S.C. PEBA. EyeMed Medically Necessary Contact Lens Claim Form EyeMed audits clinical records against submitted claims, and a code that doesn’t match the documented prescription can trigger a recoupment from future claims.
Appealing a Denial
If the claim is denied, you can appeal. Your Explanation of Benefits carries the plan-specific instructions, including the filing deadline and where to send the appeal.7EyeMed. Member Bill of Rights Appeals can be submitted by mail, email, or fax; the method and address vary by plan and state, so work from your EOB or call the Customer Care Center number on your ID card.
Every appeal must include your plan or group name, plan ID number, the claim ID number from the denial notice, and a description of the service you’re disputing.7EyeMed. Member Bill of Rights To have someone else handle it on your behalf, submit an Appointment of Representative form with the appeal. The most common denial reason on medically necessary claims is insufficient clinical documentation, so ask your provider for detailed records explaining why standard glasses are inadequate before you refile.