Subscribers: Claim Reimbursement

Out-of-Network Claim Reimbursement Form

You may not realize that you are always better off using an NVA Participating Provider. They’re conveniently located, and you’ll get more for your money there.

If you do decide to use a Non-Participating Provider and your vision benefit allows out-of-network coverage you can submit a direct claim to NVA for reimbursement according to your benefits.

How to Get Reimbursed

You can print and complete a direct out-of-network claim form, attach your receipts and send both to NVA via e-mail, fax, or mail. If your plan permits, save a stamp and use the Standard Electronic Form found after logging in. Just complete the electronic out-of-network claim form, scan and attach your receipts, then select the submit button.

Group Specific Forms (if you’re a subscriber of these groups you must use the form below)

• ShelterPoint Stand-Alone Vision Reimbursement Claim Form
• ShelterPoint XGMM Vision Reimbursement Claim Form

NVA Standard Form

• Standard Printable Form-all states but CA
• CA Claim Form