Out-of-Network
Claim Form

Please only complete this form if, at the time of service, the provider did NOT participate in the CEC network.

How to File an Out-of-Network Claim:
  • Complete all applicable fields on this form. Missing information may delay processing and reimbursement.
  • Submit one claim form for each patient to CEC within 180 days of the date of service.
  • Please upload a copy of your itemized receipt(s) for each service or product included on this claim form.
  • This form must be electronically signed by the patient or his/her authorized representative.

Out-of-network claims for services and/or eyewear obtained from an in-network provider will not be reimbursed.

 

CEC understands that vision plan members may encounter sales promotions (such as “two-for-one sales”) or steep discounts offered by some of our optical providers. As is true of most vision plans, your CEC vision plan is not intended for use in conjunction with these types of offers. In general, providers will allow only the use of your CEC vision benefit or the sales promotion (the sale price or discount).

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Patient Information

Details of the person who received the service:

If you do not know the Member ID number, please contact CEC at 888-254-4290.

Patients Relationship to Employee*

Primary Member Information

Employee Information:

Contact and Mailing Information

Where the reimbursement check should be mailed:

Request for Reimbursement

Please check all that apply.

    Accepted file types: .jpg, .png, and .pdf Max file size 8MB

    Provider or Optical Information

    Patient’s or Authorized Person’s Signature: By typing below, I authorize the release of any medical or other information necessary to process this claim.

    IMPORTANT: Reimbursements are processed within a few weeks from the date we receive your electronic out-of-network claim form. For questions about your Member ID number or eligibility, please contact CEC at 888-254-4290.

    CEC’s Customer Service reps are courteous and helpful.  They go above and beyond in assisting me with my questions."

    Carol P.
    Member Since 2007