If vsp outofnetwork coverage is included in your plan, members. Sign on to and access the outofnetwork reimbursement form and follow the instruct ions. Vsp claim form fill online, printable, fillable, blank. For additional information on your eyecare benefits, please visit or call 8008777195. For additional information on your eyecare benefits, please visit vsp. Our sitemap includes links to every page on our site, as well as rss feeds for each. For additional information on your eyecare benefits, or to submit your out of network reimbursement form online, please visit the vsp website at vsp outofnetwork reimbursement form. Oregon s public employees benefit board contracts for and administers benefits for eligible state employees.
Get the vsp claim form description of vsp claim form vsp member reimbursement form to request reimbursement, complete this form in blue or black ink, enclose a legible copy of your itemized. Outofnetwork reimbursement form submit this form along with your itemized receipt to. The expense reimbursement form is used by employees and other people who are engaged or are responsible for conducting. The itemized receipt can be scanned or you can take a picture, and save it as a. Outofnetwork reimbursement form coordination of benefits information. Submit this form along with your itemized receipt to. For instance, auto mileage, vsp, medicare, and other types of expenses. For additional information on your eyecare benefits, or to submit your out of network reimbursement form online, please visit the vsp website at vsp outofnetwork reimbursement form subscriber information. Please allow up to 10 business days plus mailing time to and from vsp for.
We provide high quality health plans and other benefits for approximately 140,000 oregonians. If vsp outofnetwork coverage is included in your plan, members can obtain services from any provider they choose, including national or retail chains. Vsp reimbursement form fill online, printable, fillable. When services andor materials are obtained from an open access provider, members have two reimbursement choices. Your itemized receipt must include the information shown below with an. You have 180 days from the date you receive services to submit your claim for reimbursement. If your plan permits a nonparticipating provider to. If you are coordinating benefits with another insurance carrier, we need a complete copy of the explanation of benefits from your primary insurance carrier. Vsp po box 997105 sacramento, ca 958997105 check here another insurance company has made payment to.
If you do not have internet access, you may call 8008070764 and request a claim form to return with an itemized receipt listing the services received. If you have receipts for other claims you must complete a separate claim form. Major medical plan benefit schedule 90kb medical plan benefit schedule 74kb injury plan benefit. Members can ask an open access provider to submit a request for reimbursement on their behalf. Help with dental and vision insurance claims principal. For employees eligible for the video display terminal vdt coverage, you must also obtain the vsp vdt confirmation form from the campus benefits office and include it with the paperwork in order to be reimbursed according to the csu plan allowances. Vision plan outofnetwork claim form please return this form with a copy of your paid, itemized receipt to. Outofnetwork vision services claim form claim form instructions to request reimbursement, please complete and sign the itemized claim form. Vsp member reimbursement form roger williams university. Reimbursement for outofnetwork services is according to. Vsp po box 997105 sacramento, ca 958997105 check here. I acknowledge that if i revoke my application form, i shall not be entitled to any severance pay or severance benefits under the vsp. If you are coordinating benefits with another insurance carrier, we need a complete copy of the explanation of benefits from. Campus login select your campus from the dropdown, then click the login button.
The reimbursement form template can be for anything. If you are coordinating benefits with another insurance carrier, we need a complete. Get the vsp claim form description of vsp claim form vsp member reimbursement form to request reimbursement, complete this form in blue or black ink, enclose a legible copy of your itemized receipts, and send them to the following address. You must pay the bill at the time of service and submit the claim to vsp for partial reimbursement. Vsp member reimbursement form health insurance for. Vsp application form department of budget and management. Vsp vision care for life is a registered trademark of vision service plan. To view pdf files, download free adobe acrobat reader. They can get started by downloading the vsp member reimbursement form pdf. Attached copies of itemized receipts to this form and mail to. Vsp po box 385018 birmingham, al 352380518 member information policyholderemployee id or last 4 digits of ssn.
We provide high quality health plans and other benefits for approximately 140,000. This claim form is intended for subscribers and covered dependents who receive services from providers outside the cigna vision network. For more information on your eyecare benefits, please visit. Missing information and receipts can delay your reimbursement. For employees eligible for the video display terminal vdt coverage, you must also obtain the vsp vdt confirmation form. Attach a copy of the itemized receipt to this form and mail to the address below. Box 997105, sacramento, ca 958997105 or fax to 9168515152 important note. Submit an outofnetwork claim if youve received eye care services from an outofnetwork provider, you may need to submit a claim to request reimbursement. Employees visiting a nonnetwork vision provider who doesnt submit claims on their behalf should visit or call 8008777195 for claim submission directions. Your benefits will always go further when you see an innetwork doctor. Reimbursement form free download printable templates lab. For additional information on your eyecare benefits, please visit our website at. Select your campus bakersfield chancellors office channel islands chico dominguez hills east bay fresno fullerton. Vsp member reimbursement form to request reimbursement, complete this form in blue or black ink, enclose a legible copy of your itemized receipts and send them to the following address.
Mileage reimbursement form 9 free sample example format reimbursement form template reimbursement form template. After completing the claim form, you may attach your receipts or print and mail copies of your claim form and receipts to. Preston street, suite 609, baltimore, md 21201revocations sent by. Return the completed form and your itemized paid receipts to. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller instantly.
Whole pet and whole pet with wellness coverage form 483kb all other plan benefit schedules. Only available to vsp members with applicable plan benefits. The vsp provider submits claims on the employees behalf. Vsp member reimbursement form to request reimbursement, complete this form in blue or black ink, enclose a legible copy of your itemized receipts, and send them to the following address. Vsp member reimbursement form vancouver, washington. Box 997105, sacramento, ca 958997105 important note. If your plan permits a nonparticipating provider to accept assignment, the provider must submit a completed cms1500 form also known as a hcfa1500 form to cigna vision at the address below. This is the document which is used to detail expenses that were incurred for the business reasons. This means members wont need to pay their entire bill up front and will only be. To request reimbursement, complete this form in blue or black ink, enclose a legible copy of your itemized receipts and. The explanation of benefits must indicate the services wh ich were received, as well as the amount paid. This is the document which is used to detail expenses that were incurred for. How long do i have to submit a claim for reimbursement. To request reimbursement, complete this form in blue or black ink, enclose a legible copy of your itemized receipts, and.