Like any great relationship, understanding who brings what to the table can make all the difference. As a member, you have certain rights and protections to make coverage fair and easy to understand. You also have responsibilities to us and to the providers that are part of our network.
We’ll keep you informed of those rights and we commit to delivering your vision care benefits in a spirit of all that follows.
You have a right to appeal your vision plan’s decisions, file a complaint or request an independent review. Neither your plan nor your provider can penalize and/or discriminate against you or your dependents for expressing dissatisfaction or filing an appeal. View notice of non-discrimination, language assistance and accessibility.
You have the right to appeal a denied claim.
You can ask for a review if we deny a claim and you do not agree. This is called an appeal. Appeals may be submitted via mail, email or fax. Refer to your Explanation of Benefits (EOB) or contact the Customer Care Center number found on your ID card for instructions.
You may appeal on your own or you may authorize someone to appeal for you. You can do this by submitting an Appointment of Representative form with your appeal.
Most plans have a specific time limit for submitting your appeal. See your explanation of benefits (EOB) or your plan booklet for specific appeal filing limits and instructions.
Response times may vary and can depend on state law and/or whether your appeal is deemed urgent. This can also differ based on the type of appeal. If you are appealing a decision for which we had to approve your claim before you got care, those timeframes differ as well.
We will decide your post-service claim appeal within 30 days unless otherwise dictated by your plan and/or federal or state law.
URGENT CARE CLAIMS: If you vision care provider believes that a delayed decision could place the member’s life, health, or ability to regain maximum function in serious jeopardy, you can request an expedited review. If we deem the request should be expedited, we will make a decision within 72 hours.
Most plans offer 1 to 2 levels of appeal. Your appeal rights are detailed within the resolution letter you’ll receive for each appeal. Please follow the directions supplied on your letter to request a review.
Each level of appeal is reviewed by a qualified independent reviewer who was not involved in the previous decision and not involved with your plan. Your plan’s regulating body calls this an independent review. The instructions differ for each regulator. Regulators impacting our plans may include:
Each appeal level has different filing limits and contact information. This information will be listed on your resolution letter.
Medicare Advantage plan members may contact Medicare at: 1.800.633.4227, 24 hours/7 days a week; TTY 711 or the Medicare Rights Center: 1.888.466.9050
You have the right to complain or appeal a complaint decision
A complaint/grievance is defined as a verbal or written expression of dissatisfaction by a member, member authorized representative, or a provider.
You can submit a complaint for any reason such as:
If you use an out-of-network provider, keep in mind they are not obligated to comply with your plan. Visit your state consumer website to learn how to file a complaint about an out-of-network provider.
You can submit your complaint/grievance request via mail, email, fax or phone. See your website, plan booklet or contact your Customer Care Center for instructions.
You may submit your complaint/grievance on your own or you may authorize someone to submit the complaint/grievance for you. You can do this by submitting an Appointment of Representative form with your complaint.
Complaint and/or grievance timeframes vary; visit your plan website or contact our customer care center for assistance at 877.226.1115; TTY 711.
A decision is typically made within 30 days unless otherwise dictated by your plan and/or federal or state law.
If we make a decision concerning your complaint/grievance and you do not agree, you may have a right to appeal this decision. You will receive a letter in response to your complaint/grievance which contains the instructions to appeal.
So you get the vision care you need, you have the ability to access services out-of-network in the event covered services are not available in network. Specifically, this applies if you are unable to: 1) schedule a visit within 2 weeks, 2) locate a participating provider within a 10-mile radius in an urban-suburban area, or 3) locate a participating provider within a 20-mile radius in a rural area.
You may not obtain the in-network level of benefits because you choose an out-of-network provider due to personal preference or an inability to reconcile your personal schedule with a provider who does have available appointments within a 2-week period.
You must submit an out-of-network claim form for reimbursement.
If you opt to receive vision care services or vision care materials that are not covered benefits under your plan, a participating vision care provider may charge you his or her normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request. In addition, not all providers may accept all vision discounts. Please contact your provider to confirm what discounts they accept.
Our organization is part of EssilorLuxottica, which has business interests in frame and lens manufacturing and retail outlets.
Member rights may differ in some states. There may be specific requirements for reviews of benefit determination appeals, and complaints and grievances.
Notice to Rhode Island members.