To get reimbursed for a visit to an eye doctor outside the Davis Vision network, you pay the provider in full at the appointment, then submit the Davis Vision out-of-network reimbursement form (officially the Direct Reimbursement Claim Form) along with an itemized receipt. Download the form by logging into your account at davisvision.com and clicking “Access Benefits and Forms,” or request a copy by calling customer service at 1 (800) 999-5431.1Davis Vision. Member FAQs Expect a check in roughly two to four weeks, and expect the amount to be considerably less than you paid.
What to Gather Before You Start
Pulling everything together up front keeps you from stalling partway through. You need:
- Your member ID number, printed on your Davis Vision ID card or shown in your online account.
- The patient’s full legal name, date of birth, and relationship to the subscriber (self, spouse or domestic partner, or child). If the patient is a dependent student aged 19 or older, some plans require written proof of school enrollment.2Davis Vision. Direct Reimbursement Claim Form
- The examining doctor’s name (with OD or MD designation), office address, state license number, and phone number. If a different provider dispensed your eyewear, you need the same details for that dispenser. One version of the form also asks for the provider’s federal Tax Identification Number.3Davis Vision. Out-of-Network Reimbursement Claim Form
- An itemized receipt showing the date of service and a breakdown of each service or product with the amount you paid. A credit card slip with a lump-sum charge won’t work; costs must be split by category (exam, frames, lenses, contacts).
You also need your provider’s signature on the form itself. Ask at the appointment, or call the office afterward and have them sign a copy and send it back. Without the provider signature, Davis Vision considers the form incomplete and may delay payment.2Davis Vision. Direct Reimbursement Claim Form
Filling Out the Form
The form has four sections, and each patient needs a separate form. If you and your child were both seen on the same visit, that’s two forms.3Davis Vision. Out-of-Network Reimbursement Claim Form
Member and Patient Information
Enter your full name, member ID, mailing address, and phone number in the member section. In the patient section, write the patient’s name, date of birth, and check the relationship box. One version asks whether you and your spouse receive vision benefits from the same employer; answer yes or no.2Davis Vision. Direct Reimbursement Claim Form
Provider Information
Fill in the examining doctor’s name, address, state license number, and phone. If someone else dispensed your glasses or contacts, use the separate dispenser section for their details. Both the examiner and the dispenser must sign in their respective sections.3Davis Vision. Out-of-Network Reimbursement Claim Form
Services and Charges
You don’t need CPT or HCPCS codes. Just enter the date of service and the dollar amount you paid next to the matching category. Standard categories are eye examination, frames, single vision lenses, bifocal lenses, trifocal lenses, elective contact lenses, and medically necessary contact lenses. Some versions also list cataract and lenticular lenses separately. Add the total at the bottom, and make sure every figure matches your receipt exactly. A mismatch is the fastest way to trigger a request for more documentation.2Davis Vision. Direct Reimbursement Claim Form
Signature and Certification
Sign and date the certification line at the bottom. Your signature authorizes Davis Vision to contact your provider for any records needed to process the claim. Without it, the claim won’t be processed.3Davis Vision. Out-of-Network Reimbursement Claim Form
Where to Send It
You can submit by mail or through the online member portal. The mailing address is printed on your specific form and varies by plan version. The two currently in circulation:
- Vision Care Processing Unit, P.O. Box 1525, Latham, NY 121102Davis Vision. Direct Reimbursement Claim Form
- Vision Care Processing Unit, P.O. Box 479, Troy, NY 121813Davis Vision. Out-of-Network Reimbursement Claim Form
Use the address on your form, not whichever looks more familiar. Mail the completed form with your original itemized receipts, and keep copies of everything first.
To submit online, log into davisvision.com and go to the Direct Member Reimbursement section. You must include either your provider’s signature on the form or a detailed receipt as part of the upload.1Davis Vision. Member FAQs Upload clear scans or high-resolution photos; blurry images are a common reason claims get kicked back. Save the confirmation screen.
How Long Processing Takes
Out-of-network vision claims are post-service claims under federal benefits law. The plan must notify you of its decision within 30 days of receiving your claim, with one 15-day extension permitted if more information is needed, and that extension must be communicated before the first 30 days end.4eCFR. 29 CFR 2560.503-1 – Claims Procedure A clean, complete form usually processes in roughly two to four weeks.
Check progress by logging in and opening the Claim Status or Member History tab. If the claim shows “pending” for more than 30 days without any communication, call 1 (800) 999-5431.5Davis Vision. Contact Us
What You’ll Actually Get Back
Out-of-network reimbursement follows a flat allowance schedule set by your plan, not a percentage of what you paid. One sample Davis Vision plan schedule shows:
- Eye exam: $48
- Frames: $36
- Single vision lenses: $36 per pair
- Bifocal lenses: $54 per pair
- Trifocal lenses: $69 per pair
- Progressive lenses: $62 per pair
- Disposable contact lenses: $1136Davis Vision. A Guide to Your Vision Benefits
Your plan’s amounts may differ. Check your Summary Plan Description or call Davis Vision for the figures that apply to you. If you paid $300 for an exam and designer frames, your check might be under $100. Only one claim per service category can be submitted per benefit cycle, except for contact lenses.6Davis Vision. A Guide to Your Vision Benefits Worth knowing before you choose to go out of network.
Why Claims Get Delayed or Denied
Most trouble comes from incomplete paperwork, not coverage disputes. The usual culprits:
- Missing provider signature. Both the examiner and the dispenser must sign. If you forgot at the office, call and ask them to sign a copy and send it to you.
- No itemized receipt. A credit card statement with a lump sum isn’t enough. The receipt must break down each service and its cost.
- Mismatched amounts. If the form says $275 but the receipt says $290, the claim gets flagged.
- Wrong form version. Some employer groups have plan-specific forms. If your benefits portal provides a particular version, use that one.
- Blank fields. A missing member ID, patient date of birth, or relationship checkbox all cause delays.
Davis Vision will contact you for more information before denying outright, but every round of back-and-forth adds weeks. Getting it right the first time matters.
Appealing a Denial or Low Payment
If your claim is denied or paid at less than you expected, you have 180 days from the date on the Explanation of Benefits notice to file an appeal.7Davis Vision. Davis Vision Appeals and Grievance Rights Information You can appeal by phone through a member service representative, but a written appeal creates a paper trail.
Send a written explanation of why you believe the coverage decision was wrong to:
Davis Vision, Inc.
Attention: Complaints and Appeals Department
P.O. Box 791
Latham, NY 121107Davis Vision. Davis Vision Appeals and Grievance Rights Information
Include the patient’s name, your member ID, the provider’s name, the date and description of the service, and the charges. Attach copies of supporting documents such as the original receipt, a letter from your doctor explaining medical necessity, or prior correspondence from Davis Vision. Keep your originals.
For post-service appeals, Davis Vision must respond within 30 days.7Davis Vision. Davis Vision Appeals and Grievance Rights Information If the internal appeal doesn’t go your way and your plan is governed by federal benefits law, you may have the right to an external review or further legal options; the denial letter should outline those next steps. The 180-day window is firm, so don’t sit on a denial notice.