CurrentBlue Cross Blue Shield - IowaPolicy N/A

VSP Member Reimbursement Form — Out-of-Network Reimbursement Instructions

Instructions and form for members to request reimbursement for out-of-network eye care services and Laser Vision procedures; applies to members with out-of-network benefits who submit claims to VSP.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyVSP Member Reimbursement Form — Out-of-Network Reimbursement Instructions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and mail the VSP Member Reimbursement Form with legible itemized receipts to the PO Box and keep a copy for your records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstimeframe to submit

PO Box 495918mailing address

provider, patient, date, amountrequired receipt fields

helplinelanguage assistance

Reimbursement Eligibility & Requirements

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyVSP Member Reimbursement Form — Out-of-Network Reimbursement Instructions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and mail the VSP Member Reimbursement Form with legible itemized receipts to the PO Box and keep a copy for your records.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Member has out-of-network benefits to be eligible to request reimbursement.
Submit within 12 months from date of service.12 months
Attach readable itemized receipts, invoices, or service statements that include: provider name, patient name, date of service (MM/DD/YYYY), complete description and amount paid.
If submitting Laser Vision claims, include which eye(s) received surgery, surgeon name, facility name, surgery date of service, type of procedure (e.g. PRK, LASIK, Custom LASIK, Custom PRK), cost of procedure, member name, member ID number, member mailing address, patient name, patient DOB, patient relationship to member, and client (employer) name; write the Laser Vision claim amount under 'Exam' on the reimbursement form.
Laser Vision warranty enhancements are not reimbursable; claims may only be submitted for surgery (one or both eyes) and/or pre/post-operative care.
If another insurer made payments, attach a copy of the statement showing payment.
Complete the fillable reimbursement form (including patient, member, claim, and provider sections), print, sign, and mail with required documentation to the PO Box address; keep a copy for your records.
Fraud warnings apply; knowingly submitting false information may result in criminal or civil penalties.
Free language assistance services are available via the phone number provided on the form.

ALL of the following

Reimbursement requests must include itemized receipts containing: name of provider (e.g., doctor, office, website, or retailer); name of patient; date service was received; complete description and amount paid for each service.

ALL of the following

Ensure all required fields on the form have a value and dates are provided in Month/Day/Four-Digit Year format (mm/dd/yyyy).

Member Submission Steps and Mailing

Documentation Required

VSP Member Reimbursement Form — Submission Instructions

To request reimbursement, complete and print the VSP Member Reimbursement Form, enclose a legible copy of your itemized receipt(s), and mail them to the address below. Be sure to keep a copy for your records. You typically have 12 months from the date of service to submit for reimbursement.

Attach readable itemized receipts, invoices, or service statements containing: Name of provider; Name of patient; Date service was received (MM/DD/YYYY); Complete description and amount paid for each service; Member's name; Member's ID number (SSN or member ID); Member's mailing address; Patient's DOB and relationship to member.
If submitting Laser Vision (LASIK/PRK) claims, the itemized receipt and/or provider letter must also include: Which eye(s) received surgery; Surgeon name; Facility name; Surgery date of service; Type of procedure (e.g., PRK, LASIK, Custom LASIK, Custom PRK); Cost of procedure; Note that Laser Vision warranty enhancements are not reimbursable; Claims may only be submitted for surgery (one or both eyes) and/or pre/post-operative care; Write the amount of the Laser Vision Care claim under "Exam" on the reimbursement form.

Note

Submission Address

Mail the completed form and itemized receipts to:

VSP
PO Box 495918
Cincinnati, OH 45249-5918

Form Fields & Receipt Requirements

inv-03: Date of Service (mm/dd/yyyy) as used on the form — field definition and format

Field labelDate of Service

Required formatmm/dd/yyyy (Month/Day/Four‑Digit Year)

PurposeEnter the date the service was received (e.g., date of exam, surgery, or date glasses were ordered)

Example03/15/2025

NotesAll required fields must have a value and dates must follow the specified format to avoid processing delays.

inv-04: Required fields for a readable itemized receipt

Required receipt fieldsProvider name; Patient name; Date service was received; Complete description of each service; Amount paid

Provider identification examplesDoctor, office, website, or retailer name must be shown on the receipt

Laser Vision-specific detailsFor Laser Vision submissions include surgeon name, facility name, surgery DOS, type of procedure, which eye(s) received surgery, and cost of procedure

Member identifiers for Laser VisionInclude member's name, member ID number, and member's mailing address on the itemized receipt or provider letter

Additional patient info for Laser VisionPatient's name, date of birth, and relationship to the member must be included when applicable