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 for each service or product included on this claim form.
- This form must be electronically signed by the patient or his/her authorized representative.
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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.
Submit another out-of-network
claim.
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