Out-of-network claims appeals

General

If you are not satisfied with a coverage decision, you are entitled to a review (appeal) of the benefit determination.  To obtain a review, you or your authorized representative should submit your request in writing to:

Provider Appeals Coordinator
EyeMed Vision Care
4000 Luxottica Place
Mason, OH  45040

Your request for a review of an adverse benefit determination must be submitted within 180 days of the date of your Remittance Advice.

A copy of the specific rule, guideline or protocol relied upon in the adverse benefit determination will be provided free of charge upon request by you or your authorized representative.

You may also review the documents relevant to your claim.

You may have other alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state’s insurance regulatory body.

Centers for Medicare & Medicaid Services

If you are not satisfied with a coverage decision, you are entitled to a review (appeal) of the benefit determination.  To obtain a review, you or your authorized representative should submit your request in writing to:

(All Other – Excluding Humana)   
Provider Appeals Coordinator
EyeMed Vision Care
4000 Luxottica Place
Mason, OH  45040
(Humana Only)
Appeals and Grievance Department Humana Inc.
PO Box 14165
Lexington, KY  40512-4165

**Humana Only – Non-contract providers may fax the appeal to 800.949.2961**

Your request for a review of an adverse benefit determination must be submitted within 60 days of the date of your Remittance Advice.

You or your representative must ask for an appeal. Your request must include:

  • Copy of the original claim form
  • Remittance Advice notification showing the denial
  • Any clinical records and other documentation that supports your argument for reimbursement
  • Reason for appealing
  • Signed Waiver of Liability Form holding the member harmless regardless of the outcome of the appeal

We recommend keeping a copy of everything you send us for your records. You can ask to see the medical records and other documents used to make our decision before or during the appeal.  At no cost to you, you may also ask for a copy of the guidelines we used to make our decision.

If you ask for an appeal and we continue to deny your request for payment of a service, we’ll send you a written decision and automatically send your case to an independent reviewer.  If the independent reviewer denies your request, the written decision will explain if you have additional appeals rights.

Resources

  • EyeMed: 877.226.1115; TTY 711
  • Medicare: 800.633.4227, 24 hours/7 days a week; TTY 877.486.2048
  • Medicare Rights Center: 888.466.9050
  • Elder Care Locator: 800.677.1116 or eldercare.gov to find help in your community