Davis Vision Medically Necessary Contacts Form 2024

Davis Vision Medically Necessary Contacts Form 2024 - MEDICALLY NECESSARY ADDITIONAL INFORMATION FORM For prior authorization submit via toll free fax 1 800 584 2329 REQUIRED INFORMATION Patient Name Patient DOB Provider Name Provider Panel Member Name Member ID Provider Telephone Date of Service Provider Fax FOR DAVIS VISION USE ONLY PLEASE DO NOT WRITE IN THE FIELDS BELOW

20 VISUAL ACUITIES OS MEDICALLY NECESSARY CONTACT LENS REQUIREMENTS Medically Necessary Visually Required Contact Lenses are only available for the diagnoses listed below CIRCLE ALL APPLICABLE Keratoconus Aphakia Aniridia K Readings and or topography

Davis Vision Medically Necessary Contacts Form 2024

Davis Vision Medically Necessary Contacts Form 2024

PURPOSE To provide the medical necessity criteria for contact lenses. Applicable procedure and material codes for medically necessary contact lenses are also defined. POLICY Background The criteria for medically necessary contact lenses are defined by lens type, procedure, and materials codes. Medically Necessary Procedures

Medically necessary contact lenses are contact lenses that are needed to correct reduced vision due to the specific eye conditions as listed below Medically Necessary Contact lenses and contact lens fittings are considered medically necessary for the following conditions and related clinical findings

Span Class Result Type

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

Eyemed Claims Address Fill Online Printable Fillable Blank PdfFiller

Aphakia Anisometropia Aniseikonia Pathological Myopia Aniridia Corneal Disorders Post Traumatic Disorders Irregular Astigmatism Additional copies of the Davis Vision criteria are available to ECPs upon request Please call 1 800 773 2847 to request additional copies

Span Class Result Type

To request claim forms please visit the Davis Vision website at davisvisionor call 1 800 401 2581 May I use the benefit at different times You may split your benefits by receiving your eye examination and eyeglasses or contact lenses on different dates or through different provider locations if desired

Medically Necessary Contacts

Which form do I use for Davis Vision Routine Vision Services Authorization Request Form for routine vision and medically necessary contact lenses may include specialty lenses contact lenses replacement glasses low vision aids additional eye exam vision therapy Note BCBS FEP authorization requests have a separate form

Medical Authorization Request Form Return fax to (855) 313-3106 (or secure email to [email protected]) Please submit authorization forms for different dates of service and individual members as separate requests. Patient Info: Patient Name: Member ID: DOB: Member's Primary Care Site (if applicable): Referring Physician Name:

Span Class Result Type

Fairfield University is pleased to provide thisinformation about your vision care plan administered by Davis Vision Inc a leading national administrator of routine vision care programs Eligibility for vision care benefits is determined by the same rules that apply to your other health care benefits

Davis Vision Medically Necessary Contacts Form 2024

Which form do I use for Davis Vision Routine Vision Services Authorization Request Form for routine vision and medically necessary contact lenses may include specialty lenses contact lenses replacement glasses low vision aids additional eye exam vision therapy Note BCBS FEP authorization requests have a separate form

20 VISUAL ACUITIES OS MEDICALLY NECESSARY CONTACT LENS REQUIREMENTS Medically Necessary Visually Required Contact Lenses are only available for the diagnoses listed below CIRCLE ALL APPLICABLE Keratoconus Aphakia Aniridia K Readings and or topography

Keratoconus Treatment With Medically Necessary Contacts Boston MA