Member rights and responsibilities
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 the right to:
- Know about and exercise your rights and responsibilities.
- Respect, consideration and dignity without discrimination of any kind. Here’s our commitment >
- Clear information about your vision plan and in-network providers. Log in to your member account to see your full benefit details. You can also check out helpful tools that walk you through how to use your benefits or understanding vision benefits.
- Timely and sufficient access to services and providers. Use our Provider Search Tool to locate eye doctors by location, hours, language preferences and more. Note: If you are logged in when using this tool, you’ll see doctors that relate to your specific network.
- Participate in your eye care decisions, including the right to refuse treatment and the right to have appropriate eye care professionals make decisions that affect your eye care experience.
- Appoint a representative to act on your behalf to obtain or give information to us or make decisions for you.
- Know why your plan denies a service or treatment.
- Appeal vision plan decisions, file a complaint or request an independent review.
- Confidentiality, protection, access, copies and the ability to amend or correct your vision care records.
- Assurance that we only use private information when necessary to obtain, pay or improve the quality of your vision care.
- Obtain vision care from qualified optometrists and ophthalmologists, and eyewear from opticians. Using a network provider ensures that the provider you select has necessary qualifying credentials and knowledge about your benefit plan.
- If your provider leaves the network or you want to see a new provider, you do not need a referral to obtain care or services from a vision care provider.
- When you live or work in an area where there are no network providers within a reasonable travel time and distance, you are eligible to receive services from an out-of-network provider at your in-network level of benefit. The exception to this right is if you choose to use an out-of-network provider based on your choice or convenience. When logged in to Member Portal, our Enhanced Provider Search will display an informational message when you enter a zip code in your network that does not have enough providers. You must submit a network access exceptions form for reimbursement.
- If you have out-of-network benefits and choose to visit an out-of-network provider, you must submit an out-of-network claim form for reimbursement.
- Seek medical emergency care for eye injuries or illness from any available medical provider. To become more knowledgeable about medical eye care coverage, contact your medical carrier. While broken glasses are not an eye care emergency, one of our in-network eye providers can review your benefits to determine if you can get a replacement pair of glasses or contacts.
- Tell us about your member experience by calling the Customer Care Center number listed on your ID card.
- Relay a concern or report potential fraud, waste or abuse practices by providers or your plan. We serve many vision plans; we need to know yours in order to understand your concern. We recommend calling the Customer Care Center number listed on your ID card to relay concerns or report fraud, waste or abuse by a provider or your plan. If you prefer to report anonymously, call 844.303.0229 or navigate to the online form speakup.essiloluxottica.com and choose EyeMed as the brand. Remember to identify your plan, so we may begin addressing your concern immediately.
- Receive information and services in other languages or alternate formats. Here’s our commitment >
- Accessible and useable equipment at your provider’s location.
- Request information about how we pay a provider.
Your responsibilities include:
- Understanding plan benefits, exclusions of coverage and costs of your eye care.
- Sharing complete and accurate health history, as well as up-to-date contact information.
- Seeking immediate care for eye emergencies and understanding how to get medically appropriate eye care services when the nearest care is out of your area.
- Offering respect and consideration to your vision provider and vision plan.
- Expressing opinions, concerns or complaints constructively.
- Letting your eye doctor know if you’re running late or need to cancel your appointment.
Appeals, complaints and grievances
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.
Appeals
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.
Your EOB or Explanation of Payment will include appeal rights specific to your state and type of insurance.
How long do I have to ask for an 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.
What should the request include?
- Plan/Group Name and/or ID Number
- Claim ID Number
- Claim Service Date
- Your name
- Your member ID number
- Your date of birth
- Any comments, documents, records or other information you would like us to consider
How long will it take for a decision to be made?
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.
You may have the right to review the decision.
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:
- ERISA/Department of Labor
- State Insurance Commissioner
- Centers for Medicare and Medicaid Services
- State Fair Hearing Office
Each appeal level has different filing limits and contact information. This information will be listed on your resolution letter.
Get help and more information about appeals by calling 877.226.1115; TTY 711
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
Complaints/grievances
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:
- Your plan
- Your provider
- Quality of care received
- Quality of service and/or materials
- Location and/or equipment
- Accessibility to a location or service
- Locating a provider in your network
- Issues obtaining an appointment within reasonable time and travel distance
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.
How long do I have to submit my complaint/grievance?
Complaint and/or grievance timeframes vary; visit your plan website or contact our customer care center for assistance at 877.226.1115; TTY 711.
What should my complaint/grievance include?
- Plan/group name and/or ID number
- Date of incident
- Your name
- Your member ID number
- Your date of birth
- Who are you complaining about?
- Provider name (if applicable)
- Name of servicing location (include address is applicable)
- Date/time of occurrence(s)
- Any comments, documents, records and other information you would like us to consider.
How long will it take for a decision to be made?
A decision is typically made within 30 days unless otherwise dictated by your plan and/or federal or state law.
You may have a right to appeal a complaint/grievance decision.
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.
About your network rights
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 network access exception form for reimbursement.
If you have an out-of-network benefit, you may choose to visit an out-of-network provider. You must submit an out-of-network form for reimbursement.
Non-Covered Services
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.
Business Interests
Our organization is part of EssilorLuxottica, which has business interests in frame and lens manufacturing and retail outlets.
STATE-SPECIFIC MEMBER RIGHTS
Member rights may differ in some states. There may be specific requirements for reviews of benefit determination appeals, and complaints and grievances. Or, there may be requirements related to how we make public health plan policies and procedures for maintaining network access.
Fraud warning
General Fraud Warning: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison.
For the states of AL, AZ, AR, CA, CO, DE, DC, FL, GA, ID, IN, KS, KY, LA, MD, ME, MN, NC, NE, NH, NJ, NM, NY, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA and WV, please refer to the following fraud notices:
- Alabama: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof.
- Arizona: For your protection, Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
- Arkansas, Louisiana, Rhode Island, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
- California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
- Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
- Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
- District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
- Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
- Georgia, Oregon, Vermont: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
- Kansas: Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud as determined by a court of law.
- Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material there to commits a fraudulent insurance act, which is a crime.
- Maine, Tennessee, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
- Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
- New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
- New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
- New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
- North Carolina: Any person with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.
- Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
- Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand ($5,000) and not more than ten thousand ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
- Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
- Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.
