Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for reimbursement.

If you saw an out-of-network eye doctor and you have out-of-network benefits, your next step is to send us your completed claim form. You can now submit your form online or by mail:

If your plan permits a non-participating provider to accept assignment, the provider must submit a completed CMS-1500 form (also known as a HCFA-1500 form) to Cigna Vision at the address below. If you receive services from a participating provider, no claim form is necessary.

Jan 4, 2024 · You will receive a one-time reimbursement based on your service frequency in your employer’s vision care plan. Complete below for glasses OR... Note: Contact fitting fees must accompany contact lenses purchased. Questions? You can call our Customer Service Department at (800) 638-3120.

To prevent possible delays, make sure to complete the claim form and include required health care provider documentation to support the claim. Written notification will be provided if additional information is needed to process a claim.

For example, if your name is Eugene Smith on your employer enrollment form, claim must state Eugene, not Gene. Name, address, and Tax ID number (TIN) of the provider of service is required.

Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network. Expenses for both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for reimbursement.

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. 4

Click below to complete an electronic claim form. Go green and get paid faster. Complete and return the following paperwork. If you will be using electronic assistive devices to complete the form, please use the online form. Claim forms must be …

If you do decide to use a Non-participating Provider and your vision benefit allows out of network coverage, you can submit a direct claim to NVA for reimbursement according to your benefits. Please reference your NVA vision benefit to ensure you have out of network coverage.