Thank You

Your out-of-network claim has been successfully submitted.

Out-of-network claim submissions are typically processed within 30 business days from submission date.

Once processed, the claim then moves into CEC’s payment process, which can take up to an additional 15 business days.

You can check the status of your out-of-network claim after 30 business days using the CEC Member Portal.

Please allow 30 business days after today’s date before checking the status of your claim, initiating an inquiry about your reimbursement or resubmitting your claim.

Out-of-Network Claim Form

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.
  • 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.

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.

Patient's 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)

Upload Receipt: 
Accepted File Types: .jpg, .png, and .pdf, Max File size 8MB

Provider or Optical Information

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