Scope of the Manual

Use this manual in combination with your patient’s Patient Record Report. If you participate in other VSP networks, we’ll provide those manuals to you.

The VSP Provider Reference Manual contains guidelines for your partnership with VSP. The core sections and their contents are:

• Eligibility and Authorization: Processes for verifying patient eligibility for VSP coverage, determining which benefits apply, and submitting claims for reimbursement.
• Plans and Coverages: Covered services and administration of Vision Service Plan^® eyecare plans.
• Eye Exams: Standard exam and supplemental test procedures for children and adults. Also includes processes for documentation requirements and referrals.
• Dispensing and Patient Lens Enhancements: Procedures for dispensing spectacle lenses and frames to patients. Also explains the use of contract labs and how to administer a necessary redo.
• Client Details: Specifics about benefits, coordination of benefits, and reimbursement.
• Policies: A listing of VSP’s policies and procedures for quality management, reimbursement, office standards, advertising, and safety.

Tools for Locating Information

The Table of Contents, lists the main manual topics by section.

The Glossary of the manual, provides an alphabetical listing of common terms used throughout this manual. A concise definition is provided for each term.

Contacting VSP

Contacting VSP by Phone and Email

 Contacting VSP by Mail

Ordering Supplies and Forms

Shipping Time

Most shipments will be sent UPS ground. Please allow the appropriate time for shipment. If you need faster delivery, please make note of the priority on your request.

Ordering Online

You may order supplies through VSPOnline on eyefinity.com.

Ordering by Phone

Call the Provider Services Support Line at 800.615.1883.

Tools and Forms Index

• Plan Reference Chart
• CMS-1500 Claim Form Quick Reference Card
• Computer VisionCare Questionnaire
• Coordination of Benefits Acknowledgement
• Explanation of Payment Quick Reference Guide
• First-Time Redo Verification Form
• Frame Benefit Examples/Frame Calculator
• Interactive Voice Response Quick Reference Card
• Low Vision Verification Form
• Material Invoice Form
• Materials Invoice Quick Reference Card
• Materials Verification Form
• Member Complaint/Grievance Forms (National/California-Only/California-Spanish/California-Chinese)
• Primary Care Provider Communication Form
• Provider Dispute Resolution Request & Multiple Provider Dispute Resolution Forms
• Safety Requirements Questionnaire
• Vision Benefit Statement
• Vision Therapy Verification Form (ICD-10)
• VSP Savings Statement (with 20% discount) (without discount)
• Current VSP Signature Lens Enhancements Chart

Explanation of Payment Message Codes

VSP Signature Plan^® Lens Enhancements Charts

September 1, 2024 Signature Plan^® Lens Enhancements Chart

Determining a Patient's Eligibility

Authorizing Coverage and Benefits

Before providing services, make sure your patient is eligible for benefits by retrieving an authorization. At that time, you’ll get information about your patient’s plan, coverage, and current benefit eligibility. You’ll also get a unique authorization number for your patient. Remember: an authorization number doesn’t guarantee payment. Review any comments or notations at the bottom of the Patient Record Report to confirm patient eligibility. Confirmation is required to show that the services and materials provided meet our plan requirements before issuing payment.

There are two ways to get an authorization number:

1. eClaim: Log onto eyefinity.com, go to the eInsurance tab or select Get Authorizations & Check Eligibility.

Click Member Search. Enter any one of the following valid search combinations:

• Full Member ID only. (Member ID can be SSN or Client-Specific Employee ID)
• Member first name, member last name, and date of birth (DOB).
• Last 4 SSN, member last name, and member first name.
• Last 4 SSN, member last name, member first name, and date of birth (DOB).
• Last 4 SSN, member last name, and DOB.

Note:

Enter more information for best results. Try SSN or Member ID to locate all records.

Important! 

Make sure you choose the correct member and patient prior to issuing an authorization. If you’re not sure which member to choose, call VSP at 800.615.1883 for assistance.

2. Customer Service: Call VSP at 800.615.1883. Select “1” to use our automated phone system. Or, you can talk with a Customer Service representative who’ll check the patient’s current eligibility, provide plan information, and issue an authorization number.

Important! 

Authorizations are usually effective for 30 days from the issue date. You’ll receive an ‘Invalid Authorization’ error message in eClaim if you submit a claim for a date of service not within the effective dates. If this happens, obtain a new authorization valid for the date of service and resubmit.

Refer to the Patient Record Report or the Lens Enhancements Charges Report for an explanation of your patient’s coverage.

Important! 

Before ordering or providing services, tell your patients that they’re responsible for payment of non-covered services and materials.

VSP patients have the ability to access and/or print a Member Vision Card from vsp.com, and may provide a card when visiting your practice for services.

Note:

A Member Vision Card isn’t required for services.

While the card will provide basic benefit/plan information, please don’t rely on it solely for benefit coverage information. You must verify your patient’s eligibility and obtain an authorization on eyefinity.com. To view what information is available on the card, please refer to the Member Vision Card Quick Reference Guide.

Submitting Claims/Timeliness

In most cases, we process claims that are received within 180 days of the date of service. Please note that when glasses are ordered, we won’t receive a claim until the lab finishes the order and submits the claim to VSP.

Remember to bill your U&C fees on all claims. We’ll pay the lesser of the billed amount or your assigned fee. To confirm claim status, visit eyefinity.com, or call VSP at 800.615.1883.

A “clean” claim is a claim that can be processed without additional information from you, your patient, or someone else.

When any part of a claim is found to be false, VSP will deny payment for the entire claim. There is no entitlement to partial payment of a claim. Denial of the claim may occur when the claim is submitted or upon subsequent review during the course of an audit.

It’s your responsibility to get an authorization and ensure the information is accurate. Payment could be delayed if you submit a claim without an authorization number. An incorrect authorization number could result in claim denial and/or you may incur lab charges. Authorization numbers can’t be transferred between claims.
When submitting claims, please complete all fields to accurately show the services you provided.

When we request dates of service, we’re looking for:

Exam: the date you performed your patient’s eye exam.

Glasses: the date your patient ordered their glasses.

Contacts: the date the contact lens fitting and evaluation started. If you didn’t perform a contact lens fitting and evaluation, use the date when contact lens materials were ordered by your patient.

It’s your responsibility to get an authorization and ensure the information is accurate. Payment could be delayed if you submit a claim without an authorization number. An incorrect authorization number could result in claim denial and/or you may incur lab charges. Authorization numbers can’t be transferred between claims.

When submitting claims, please complete all fields to accurately show the services you provided.

Important! 

You’re responsible for all claims submitted by you, your employees, and agents of your practice.

Please remember you can’t disclose any information about your patient to any other person or organization without the written consent of your patient, legal guardian, parent, or his/her authorized representative unless:

• Your patient is unable to give written consent, or
• State or federal law requires disclosure.

Standard procedure requires you to collect and report encounter data, which is specific patient information that serves the purposes stated below:

• Supports the role of optometrists as healthcare providers.
• Meets reporting guidelines required by regulatory agencies.
• Documents the efficiency, quality, and cost effectiveness of care provided.
• Demonstrates the value of vision care in treating and managing diseases, as well as maintaining overall good health.

Submitting Patient Conditions Requirement

Doctors are required to submit patient conditions through eClaim on eyefinity.com, practice management software, or paper claims. Patient condition submission is monitored as part of the Quality Assurance (QA) Program and results are provided in the QA Review Summary. Outcomes identifying the need for improvement will require the doctor’s acknowledgement of the results and an improvement action plan.

Refer to the following section to learn more about the importance of indicating patient conditions on your VSP claims, including the opportunity for additional reimbursement.

• Policies

Submitting Patient Conditions Requirement

You can easily indicate patient conditions using the eClaim form by checking the appropriate condition box(es) or by including the respective diagnosis code(s) under the “Check condition(s) patient is known to have” section.

For all practice management systems, including Eyefinity Practice Management, OfficeMate^®, and AcuityLogic^TM, you can indicate patient conditions by checking one or more of the condition checkboxes or by using the applicable diagnosis codes included below.

Notes: 

If you enter an equivalent diagnosis code, eClaim will check the box for you.
Patient Condition Sticky Notes are available for you to collect patient conditions and keep them top of mind throughout the exam process and serve as a reminder to indicate the condition when submitting the claim. Sticky notes can be ordered for free on the Supply Request Form on VSPOnline at eyefinity.com.

Check one or more of the boxes or enter diagnosis code(s) for the following:

• Diabetes. Patients who either self-reported having diabetes or are taking medications specifically for diabetes.
• Diabetic Retinopathy. Patients who have diabetic retinopathy, regardless of whether they have been diagnosed with diabetes.
• Hypertension. Patients who either self-reported being diagnosed with hypertension or those who are taking medications specifically for hypertension.
• High Cholesterol. Patients who either self-reported being diagnosed with high cholesterol or those who are taking medications specifically for high cholesterol.
• Glaucoma. Patients who have been diagnosed with glaucoma at any time, including the current visit.
• ARMD (Age-related Macular Degeneration). Patients who have been diagnosed with ARMD at any time, including the current visit.
• At Risk for Prediabetes. Patients who either self-report as having prediabetes or have been identified as being at risk for prediabetes using an online risk assessment.

Dilation

Choose Yes or No in the drop-down menu in eClaim when asked if dilation was performed. If dilation is not performed for a patient with diabetes, be sure to document the clinical rationale in the patient’s medical record.

Primary Care Provider (PCP) Communication

Choose Yes or No in the drop-down menu when asked if the PCP Communication was completed. If you did not communicate with the PCP for a patient with diabetes, be sure to document the reason in the patient’s medical record.

For more information on Eye Health Management visit VSPOnline at eyefinity.com, go to Programs, and click Eye Health Management Program.

Note: 

Tools for communicating with your patients’ PCP can be found on VSPOnline. Under Administration select Submitting Patient Conditions and then click on the Resources tab.

Use the check boxes to indicate patient conditions; diabetes, diabetic retinopathy, hypertension and/or high cholesterol on eClaim. Submit additional conditions like glaucoma, age-related macular degeneration, patients at risk for prediabetes, and other conditions using diagnosis codes.

Glasses

• Complete the Invoice Services page first to provide the material order details.
• Select a VSP contract lab.
• Click on Calculate HCPCS & Continue.
• Enter refractive error reason(s), then any additional diagnosis codes for any other medical conditions.
• Select the appropriate patient condition checkbox(es).
• Complete the Diagnosis & Services page by entering your U&C fees next to the correct CPT/HCPCS code.

Contact lenses

• Select the type of contacts dispensed.
• Select the contact lens reason (see Contact Lens Plans in the “Plans & Coverages” section of this manual).
• If contact lens exam services (fitting and evaluation) were performed, include this in the correct drop-down box.
• Indicate the contact lens manufacturer
• Specify the contact lens brand
• Enter the number of boxes
• Specify the Modality
• Click on Calculate HCPCS
• Enter refractive error reason(s), then enter any additional diagnosis codes for other medical conditions.
• Select the appropriate patient condition checkbox(es).
• Complete the Diagnosis & Services page by entering your U&C fees next to the correct CPT/HCPCS code.

Flexible Spending Account (FSA)

Some of our clients have asked us to collect and report patients’ total FSA eligible out-of-pocket expenses to their flexible spending account vendors. For these patients, the Patient Record Report will indicate, “This patient may participate in a Flexible Spending Account (FSA) program.”

You’ll also notice a field titled FSA on eClaim to collect the patient's total FSA out-of-pocket expenses. This amount includes both the VSP out-of-pocket charges you calculated in Box 29 and any eligible charges for non-covered items you do not include on the VSP claim (like second pairs and contact lens solution). Report the total for the FSA after the secondary COB payment has been deducted from the patient's primary out-of-pocket charges.

Here’s a list of common FSA eligible expenses, which is subject to change based on IRS regulations:

• Copays
• Lens enhancements
• Frame overages
• Contact lens overages
• Contact lens solution
• Additional prescription glasses not covered by the benefit
• Prescription sunglasses not covered by the benefit
• Plano sunglasses not covered by the benefit (if deemed medically necessary by the doctor)

Here’s an example to help you calculate what should be entered in the FSA box for a patient who uses VSP benefits for glasses and pays for contact lenses, contact lenses services, and solution privately:

We primarily use two paper claim forms: the CMS-1500 form and the VSP Materials Invoice form. Please refer to the CMS-1500 Claim Form Quick Reference Card and the Materials Invoice Quick Reference Card in the Tools & Forms section of this manual for instructions on completing these forms, including where to enter the Authorization Number and/or the Materials Verification number.

Using the CMS-1500 Form

Refer to the CMS-1500 Claim Form Quick Reference Card for detailed instructions. We will only accept original, red copy CMS-1500 forms. Photocopies or faxed forms will be rejected.

To expedite processing when submitting CMS-1500 claims, be sure to:

• Check that all patient information is complete and correct.
• Check that Boxes 12 and 13 have correct signatures or indicate a signature is on file.
• Use valid, complete diagnosis codes. Always code to the highest degree of specificity when indicating diagnosis.
• Enter additional diagnosis codes for any other medical conditions your patient may have.
• Enter the correct place of service in Box 24B.
• Include a letter in Box 24E that “points” to the appropriate diagnosis in Box 21.
• Include doctor NPI in Box 24J if multiple doctors are using the tax ID in Box 25.
• Complete Box 32 with the practice’s physical address, not a PO Box.

CMS Plus Materials Invoice (CMS-Plus)

If a plan requires the use of a contract lab, and you dispense lenses and/or frames to an eligible patient, use a Materials Invoice Form with the CMS-1500 Claim Form. If you don’t use a contract lab, or if you provide only an exam or dispense contact lenses, submit only the CMS-1500 Form.

If you need to submit a Materials Invoice Form with the CMS-1500 Form:

1. Complete both forms.

2. Attach the two completed forms.

3. Send both claim forms to the lab. (The lab will forward the claim to VSP for payment after the glasses have been made)

Contract Lab Orders

The lab will fill orders that contain lenses and frames, and forward the claims to us for payment.

If the lab contacts you about a missing or incomplete CMS-1500 Claim Form, submit a completed form to the lab as soon as possible. If a completed form isn’t received within 10 working days of initial notification, the lab can’t fill your order and will return the Materials Invoice Form to you.

It’s your responsibility to check patient eligibility for materials and to correctly complete the forms. If a material claim is denied payment, any materials you order will be billed to you, and you'll be responsible for paying the lab.

In most cases, we process claims that are received within 180 days following the date of service.

Remember: 

When lenses and frames are ordered, we don’t get the claim until the lab completes the order and submits the claim to us.

Materials Codes on CMS-1500 Form

It’s important that you list any materials sold (lenses, frames, and lens enhancements), with the appropriate V code, on the CMS-1500 Claim Form as we’ll reimburse you only for services listed on the CMS-1500 Form. The information provided on the Materials Invoice Form is only for lab use. The following are samples of Comment Codes and the appropriate forms and actions:

CMS-1500 Form Comment Codes and Claim Filing Actions

If you’re away for a period of time and use a substitute or fill in provider, you can submit a claim using eClaim or paper.

• Submit the claim under your NPI and Tax ID number
• Include the substitute or fill in provider’s NPI or SSN in box 19 “Reserved for Local Use” and a modifier for each line – use modifier Q5

Claim Appeals

To dispute/appeal a claim based on an individual claim denial, a bundle of claims denial or dissatisfaction with a claim payment, you may appeal by filing a claim dispute or appeal. See Appeal Process below.

For other disputes, including disputes related to Network Doctor Adverse Actions and actions as a result of an audit conducted pursuant to VSP’s Fraud, Waste and Abuse Policy, please see VSP’s Dispute Resolution Policy under the Policies section of this manual. The Fraud, Waste and Abuse Policy can be found under this same section.

To check the status of a claim, call VSP at 800.615.1883 or access eyefinity.com.

For claim corrections, such as a diagnosis code, billed amount or service code, call VSP at 800.615.1883 or complete the claim correction form on eyefinity.com.

VSP considers you to be authorized to act on behalf of your patient in pursuing appeals of denied claims. It’s your responsibility to:

• Inform patients of their right to appeal a claim denial.
•  Explain the appeal process to your patients.
• Get your patients’ approval to act as their authorized representative in the appeal process. If your patients don’t agree to you representing them in the appeal process, please direct them to contact VSP Member Services at 800.877.7195.

This Appeal process is for disputes/appeals related to individual claim denials, a bundle of claims denial or your dissatisfaction with a claim payment. All other disputes shall be submitted pursuant to VSP’s Dispute Resolution Policy cited above.

All Appeals under this section can be submitted online, by mail, or by phone. Incomplete appeals will be returned.

A sample Provider Claim Dispute Request Form is provided in the Tools & Forms section of this manual. If you prefer to submit a written appeal without using the form, please include the following information with your written appeal:

1. Your name and Payment Arrangement ID number
2. Your contact information
3. Original claim number (listed on the Explanation of Payment)
4. Supporting documentation

You can appeal multiple “like” denials (i.e., numerous claims denied for untimely filing) at the same time by using the Multiple-Provider Claim Dispute Form with the Provider Claim Dispute Request.

For most states and plans, appeals must be submitted to us within 180 calendar days from the date of the Explanation of Payment. See state and plan exceptions for specific timeframes and rules.

• Online: Complete the Provider Claim Dispute Request Form available in the Forms Library under Administration on VSPOnline on eyefinity.com.
• Mail: Send appeals to: VSP Claim Appeals, PO Box 2350, Rancho Cordova, CA 95741-2350.
• Phone: Call VSP at 800.615.1883 (California and New Mexico Provider Disputes must be received in writing)

We’ll review your appeal and send a written response within 30 calendar days for most states and plans. Should the initial denial be upheld, you have the right to pursue a second-level appeal. Second-level appeals must be received within 60 calendar days from the date of the letter stating that the appeal has been denied. Follow the same process listed above to submit second-level appeals.

Arizona

Arizona Medicaid has unique requirements. For more information, see Submitting Claims/Billing, Reimbursement, & Appeals section in the Arizona Medicaid Manual.

California

Appeals unrelated to Notices of Adverse Action and actions as a result of an audit conducted pursuant to VSP’s Fraud and Abuse Policy (See above under “Claim Appeals”) must be submitted to us within 365 calendar days from the date of the denial. Califorina Medicare must submit to us within 60 calendar days from the date of the denial. We’ll review your appeal and send a written response within 45 working days.

If you believe all or part of this claim has been wrongfully denied, you may have the matter reviewed by the California Department of Insurance at: 
California Department of Insurance, Health Claims Bureau
300 South Spring Street, South Tower
Los Angeles, CA 90013, www.insurance.ca.gov 
800.927.4357 (HELP) TDD: 800.482.4833.
 

Missouri

Appeals submitted from providers in Missouri must be received within 180 calendar days of original receipt of claim denial. We’ll review your appeal and send a written response within 20 business days from the date of receipt of all information needed to process the appeal.

New Jersey

Appeals submitted from providers in New Jersey must be received within 90 calendar days of original receipt of claim denial. We’ll review your appeal and send a written response within 10 business days from the date of receipt of all information needed to process the appeal.

Our internal second-level appeal is optional for New Jersey doctors. Following state law, New Jersey doctors have the right to use an external second-level appeal after participating in our first-level appeal process.

If you choose this option, we’ll share the cost of the arbitration equally. To initiate this process, submit the appeal in writing to an independent arbitrator listed with the American Arbitration Association and send a copy to us at: VSP Claim Appeals, PO Box 2350, Rancho Cordova, CA 95741-2350.

Here is additional contact information if you need additional information:

American Arbitration Association
Customer Service: 800.778.7879, 212.484.4181
Web site: adr.org
NJ E-mail: casefiling@adr.org

ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for people covered under these plans. If your patient’s employer pays for all or part of the patient’s benefits, the patient has additional appeal rights mandated by ERISA.

Under this law, patients can get copies of all documents, records, and other information relevant to their appeal free of charge.

Once all mandatory appeals have been completed, ERISA patients may have other voluntary alternative dispute resolution options, such as mediation. Your patients may refer to their Evidence of Coverage (EOC) or Standard Plan Description (SPD), contact their local U.S. Department of Labor Office or their State Insurance regulatory agency to find out what’s available.

ERISA patients have the right to contest the decision of the appeal process. Under ERISA Section 502(a)(I)(B), patients have the right to bring civil actions. This right can be exercised when all required reviews of their claims (including the appeal process) have been completed, the claim wasn’t approved (in whole or in part), and a patient disagrees with the outcome.

Some clients require VSP to provide their members with a Vision Benefit Statement (VBS) instead of the current VSP Savings Statement. The VBS provides patients with a summary of the amount they have been charged for the services received and will also provide any denial procedures directly to the patient. If a client requires VSP to provide a VBS, the Patient Record Report will state: Patient will receive Vision Benefit Statement (VBS) directly from VSP; a VSP Savings Statement will not be available.

View a sample of the Vision Benefit Statement.

Coordination of Benefits

Some patients have vision coverage from more than one benefits plan, either multiple VSP plans or a VSP plan and a medical plan. In these situations, coordinating benefits will help your patients maximize their coverage and lower costs. This section includes guidelines for coordinating benefits for your VSP patients. Every practice and patient is unique, and these guidelines are intended to provide best practices to help realize the full value of your patient’s coverage. You can also find guidelines for supplemental plans under that plan’s information in the Plans and Coverages section.

Please discuss billing options, including coordination of benefits (COB), with your VSP patient to identify ways to maximize value for them and create additional revenue opportunities for your practice.

If your patient requests COB, the following guidelines apply when your patient’s coverage is with two VSP plans or when a non-VSP plan is primary and a VSP plan is secondary.

If your patient’s VSP plan is primary and any other insurance plan is secondary, call VSP at 800.615.1883 to request a letter detailing your patient’s out-of-pocket expenses that can be shared with the secondary insurer.

Determining and Applying Benefits

There are several common COB situations, including VSP primary to another carrier, multiple VSP plans, health plan or Medicare with VSP coverage, routine versus medical services, and VSP secondary to another vision carrier. This section includes guidelines for coordinating benefits for your VSP patients.

Use the following to assist your patient in maximizing the eyecare benefits (vision or medical).

1. Based on your professional judgment, determine if the service is routine or medical.
2. Determine the primary and secondary plans.
3. Verify eligibility and available services under each plan.
4. Determine patient responsibility, based on primary insurance.
5. Submit the primary and secondary claims, following the appropriate Submitting Claim instructions.
6. Apply total COB secondary allowance, less any secondary copays, to patient's total primary out-of-pocket expense. Patient pays remaining balance, but not more than the allowed amount.

Review the scenarios below to help determine your patient’s primary and secondary plans, if your patient is covered under multiple plans and isn’t a dependent child. If none of the scenarios fit, the plan that’s covered your patient longest is primary.

Use the following chart if your patient is a dependent child with VSP coverage as primary and secondary.

*Important! 

Obtain the length of coverage or custody information from your patient or member. Parental custody information may apply when determining coverage for a child.

VSP primary to another carrier

When a VSP plan is primary, apply benefits as you would in the absence of any other plan. If needed, call VSP at 800.615.1883 to request a letter detailing your patient’s out-of-pocket expenses that can be shared with the secondary insurer.

Quick Tip: 

If your patient isn’t eligible for a service under the primary plan, the secondary plan may be used as primary for that service.

Multiple VSP plans for routine services:

1. Determine the primary and secondary plans.
2. Review Coordination of Benefits between Multiple VSP Plans to verify VSP plans can coordinate.
3. Verify eligibility and if any services are exhausted under either plan.

Quick Tip:

If your patient isn’t eligible for a service under the primary plan, the secondary plan may be used as primary for that service.

4. Determine the patient’s out-of-pocket expenses from the primary plan.
5. Refer to the Secondary Allowances schedule to determine the COB amount for each service payable under the primary plan that is also available under the secondary plan.

Quick Tip: 

Be sure to review COB rules on primary and secondary authorizations prior to calculating COB secondary allowance.

6. Deduct total available COB secondary allowance from patient’s total primary out-of-pocket expense. Patient pays remaining balance.

Quick Tip: 

You can also access the COB Calculator on VSPOnline to help determine the amounts a patient can coordinate for routine services when VSP is secondary.

7. Bill VSP using the primary plan authorization number and reference the secondary plan’s authorization. See Submitting COB Claims for detailed instructions.

When a VSP plan is secondary, follow these steps:

1. Verify eligibility and if any services are exhausted under either plan.

Quick Tip: 

If your patient isn’t eligible for a service under the primary plan, the secondary plan may be used as primary for that service.

2. Determine whether your patient is eligible for benefits under the secondary plan
3. Refer to the Secondary Allowances schedule to determine the COB amount for each service payable under the primary plan that is also available under the secondary plan.
4. Deduct total available COB secondary allowance from patient’s total primary out-of-pocket expense. Patient pays remaining balance, but not more than the allowed amount.

Quick Tip: 

You can also access the COB Calculator on VSPOnline to help determine the amounts a patient can coordinate for routine services when VSP is secondary.

5. Bill VSP as secondary. See Submitting COB Claims for detailed instructions.

Members may have coverage under both VSP and a health plan or Medicare.

Common scenarios:

• If you participate on the patient’s health plan and the exam is medical, bill the health plan or Medicare as primary.
• If the exam is routine, bill VSP as primary unless the patient has routine coverage through their health plan*
• If the health plan covers the exam only, submit the exam claim to the health plan as primary and the materials claim to VSP as primary.

Quick Tip: 

Be sure to obtain two separate authorizations – one to submit your exam to coordinate benefits and one to submit the materials to VSP as primary.

Medical plans generally have higher copays than VSP and may have deductibles. They also don’t typically cover a refraction. To save money for your patient, coordinate benefits with VSP to help cover unpaid portions of the medical eye exams, if any, including the refraction and other medical services. Plus, you now have options to help maximize your patient’s plan.

• If another insurance carrier is primary to VSP, you can now coordinate both their routine and medical benefits (i.e. medical exam and refraction using a WellVision exam benefit and Essential Medical Eye Care) – a medical and refractive diagnosis is required.

Quick Tip: 

Be sure to include applicable medical diagnosis codes for the eye exam and any medical procedures with a routine diagnosis code for the refraction.

*Patients covered under the Federal Employees Dental and Vision Insurance Program may have routine coverage through their health plan. For more information, check the Federal Government Client Details in the Choice Network Manual.

Important! 

The primary and secondary plans must be under different ID numbers or different clients, unless there are special comments, or if COB rule 11 applies.
Interim benefits are not available for coordination under any plan benefit type whether considered primary or secondary.
If another insurance carrier is primary to VSP, you can now coordinate both their routine and medical benefits (i.e. medical exam and refraction using a WellVision exam benefit and Essential Medical Eye Care) – a medical and refractive diagnosis is required.

Note: 

If your patients have plano coverage available on the primary benefit, they must have plano coverage available on the secondary benefit to coordinate both plans when receiving plano materials.

COB Routine Secondary Allowances

Secondary allowances are less secondary plan copays and are cumulative.

Other Secondary Allowances:

•  For patients with an Elective Contact Lens Benefit, refer to the Patient Record Report for the contact lens allowance. (Note: A covered-in-full contact lens exam does not have a secondary COB dollar value).
• For patients with allowance plans, refer to the Patient Record Report for the material allowance.
• You can coordinate the secondary exam allowance with the exam, refraction and/or retinal screening out-of-pocket expense from the primary plan.
• Essential Medical Eye Care secondary exam (CPT codes 92XX and 99202-99215) amounts are reimbursed according to VSP Signature Plan Payables less any applicable copays. Additional covered services are reimbursed up to the maximum allowable amount of Essential Medical Eye Care. 

Medicaid Network Coordination of Benefits Secondary Allowances

Refer to your Medicaid Manual for state-specific Medicaid COB guidelines.

VSP to VSP for Exam, Lens and Frame

Health Plan or Medicare, VSP secondary for Exam and Refraction using WellVision Exam benefit

Health Plan or Medicare, VSP secondary using WellVision Exam and Essential Medical Eye Care

With the exception of the secondary allowances, the VSP Advantage Plan, VSP Enhanced Advantage Plan, and VSP Essentials Plan COB guidelines are the same as the VSP Signature Plan and VSP Choice Plan. If you’re not participating in the Advantage Network and the member wants to use their secondary plan to coordinate benefits, we’ll reimburse the patient based on their non-VSP provider reimbursement schedule (if out-of-network coverage is available).

COB Client Exception Rules

There may be a client exception to how you would handle your patient’s COB. Before providing services to your patient, please obtain a Patient Record Report from eClaim on eyefinity.com. The Patient Record Report will highlight the rules from the following list that may apply to your patient’s coverage and ability to coordinate benefits. Call VSP at 800.615.1883 if you have questions.

• COB rule 1: If both members are covered by the same client, COB isn’t allowed for either of the members or their children. If the member is covered twice by the same client, COB isn’t allowed.
• COB rule 2: If both members are covered by the same client, children are covered only under one parent's plan. COB can’t be applied and the child may only receive one set of services. This applies both to biological parents and step-parents.
• COB rule 3: If both members are covered by the same client, the secondary plan can be used to cover copays only, which will use all service areas.
• COB rule 4: This rule applies only when the patient has an insurance carrier other than VSP as primary. If both plans are through VSP, this rule doesn’t apply. However, other COB rules may still apply. COB reimbursement is calculated by subtracting what the primary carrier paid from what VSP would have paid as primary.

• COB rule 5: A married couple, or domestic partners, who are covered by the same client may coordinate benefits, but can’t receive two sets of services.
• COB rule 6: COB isn’t allowed for Computer Vision Care (CVC), Repair, Safety Eyecare, or ProTec Safety benefit types.
• COB rule 7: A married couple, or domestic partners, who work for the same client may either use both of their benefit plans separately to receive two sets of services, OR COB their secondary benefits to pick up only the primary copays (using all services).
• COB rule 8: If a member’s dependents have vision coverage through their own employment, coverage through that employment is primary. If dependents have coverage under Medicaid State Children’s Healthy Insurance Program (SCHIP), there’s no COB.
• COB rule 9: COB isn’t allowed. Call VSP at 800.615.1883 for client exceptions and specific instructions.
• COB rule 10: A child covered under both parents’ plans will always use the father’s plan as primary.
• COB rule 11: Employees and dependents can use their second-pair coverage towards overages from their first-pair coverage.
• COB rule 12: If both members are covered by the same client, COB is allowed to cover out-of-pocket expenses only, but the patient can’t receive two sets of services.

Submitting COB Claims

When VSP is Primary

Submit the claim as you would in the absence of any other plan.

Quick Tip: 

If your patient isn’t eligible for a service on the primary plan, the secondary plan may be used as primary for that service

Submitting the claim electronically:

1.  Get authorizations for both primary and secondary benefits.
2.  On the primary authorization, enter the services performed, calculate the HCPCS codes and enter your usual and customary fee(s).
3.  Mark “No” for question 11d in the Insured section.
4. Enter the secondary authorization number in the VSP COB Coordination of Benefits Secondary Authorization field.

Quick Tip: 

If your patient isn’t eligible for a service on the primary plan, the secondary plan may be used as primary for that service

Recognizing the complex nature of COB can be a barrier to adoption. VSP has simplified the process when Medicare, a health plan or a non-VSP insurance carrier is Primary and VSP is Secondary:

• Maximize member benefits – You can now coordinate both their routine and medical benefits (i.e. medical exam and refraction using a WellVision exam benefit and Essential Medical Eye Care).
• Expanded electronic filing capabilities – You can now submit secondary COB claims electronically, regardless of services provided, with new fields to enter the primary plan’s payment (no more paper, just keep a copy of EOP in the patient’s chart).
• Simplified claim submission – you can now coordinate secondary benefits in a single claim submission when VSP is secondary and tertiary or when using the patient’s medical and routine eye care plans (just key the 2nd auth in the COB Secondary Authorization box)

How it works:

If we’re the secondary payor, bill us for your patient’s out-of-pocket expenses. Examples are copays, coinsurance, deductibles on High Deductible Health Plans or charges for non-covered services by the primary carrier.

If a member has medical benefits under another health plan, that plan is primary and VSP is secondary. If you participate on the patient’s health plan, coordinate benefits between the health plan and VSP. In these situations, coordinating benefits will help your patients maximize their coverage. You’re responsible for verifying other coverage, as well as billing and collecting from other carriers.

VSP will coordinate the non-covered portion of the services (exam, refraction, materials) with a patient’s routine benefits, if the claim includes a routine diagnosis – in addition to a medical diagnosis code, if applicable. We’ll only coordinate Essential Medical Eye Care and Diabetic Eyecare Plus Program^SM benefits with services provided for medical eyecare and this requires a medical diagnosis is the first position.

If both routine and medical services were submitted to the primary carrier with corresponding routine and medical diagnosis codes, you can now coordinate using a patient’s VSP routine and medical plans to pay toward patient out-of-pocket expenses. We follow plan policies for reimbursing these charges. However, we don’t pay more for approved services than what you would have received if we were the primary carrier.

Tips:

• If you can verify the health plan or Medicare’s eligible services and non-covered patient responsibility amount at the time of billing, you can now submit the Secondary Plan exam only claim electronically on the same day. You’ll still need to keep a copy of the original claim and Explanation of Payment or Explanation of Benefits in the patient’s file.
• If you are unable to verify the patient responsibility, wait until you receive payment from the health plan or Medicare before submitting the Secondary claim to avoid unnecessary claim corrections, as you are responsible for reconciling payments. For Medicare or Medicaid patients, overpayments must be corrected within 60 days.

Submitting the claim electronically (new eClaim):

1. Provide the same diagnosis and CPT/HCPCS codes to match the claim to insurance carrier.

2. Select Yes (Box 11d) there is another health benefit plan for eyecare. This will open a new section.

• Leave the field for Secondary Authorization blank – unless there is a second VSP plan to COB.

3. Complete the Other Insured section:

• Enter the first and last name of the insured person on the patient’s primary insurance plan in box 9
• Enter “NA” in box 9a
• Enter the patient’s primary insurance plan name in box 9d

4. Scroll to the Services section to enter the following in the COB fields for each service based on your Explanation of Payment (EOP):

• In the Other Ins Allowed field, enter the maximum amount allowed by the other insurance.
• In the Other Ins Paid field, enter the amount paid by the other insurance.
• In the Other Ins Pat Resp field, enter the remaining balance the patient is responsible to pay

Important:

If VSP is tertiary, enter the allowed amount from the primary EOP and the combined paid amounts from the primary and secondary carriers, along with the patient’s final out-of-pocket expense.

• In the Denied or Paid $0.00 Reason drop-down menu, select the reason the primary EOP indicated that the claim was denied or paid $0.00. If the reason isn’t listed, submit on paper.

5. In the Additional Information section, enter “Secondary COB claim” in box 19. Additional Claim Information.

6. If you need a copy of the claim with the COB details, click Print in the top navigation bar; it’s not on the CMS Report or Service Report.

Download our step-by-step guide to filling out your claim electronically

Submitting the Claim on paper

When you receive payment from the primary Vision Plan, submit the following information to us within six months from the issue date of the Explanation of Payment (EOP) or Explanation of Benefits (EOB) of the primary plan (Medicare, Health Plan or Vision Plan):

1. A copy of the EOP indicating patient expenses and/or service denials from the primary carrier. Don’t send a summary.
2. A copy of the original CMS-1500 claim form. Enter VSP’s authorization number in Box 23.
3. If an additional benefit will be used, enter “Tertiary COB auth ########” (additional authorization #) in Box 19. 

COB Resources

The following are resources to help you when coordinating benefits for your patients.

COB Billing Guide

Download our step-by-step guide to filling out your claim electronically

Download and print in your office today

The COB Calculator is available to providers in the Calculators section on VSPOnline.

Available for Signature, Choice, Advantage and MESSA plans.

Be sure to verify who is primary versus secondary before using the calculator.

Since some clients have restrictions, check for COB rules that would over-ride the COB Calculator.

For Exam-only claims, you can select either the Glasses or the Contacts tab.

• Be sure to check for eligible services:
• Verify whether the patient has already used or is using all applicable services under the primary plan to maximize their coverage.
• Verify service availability on the Secondary Plan that the patient will use toward the Primary Plan's out-of-pocket expenses.

Steps to Using the Calculator

1. On the appropriate Tab (Glasses or Contacts), uncheck any services the patient does not want to use or is not eligible.

2. Calculate the patient’s out-of-pocket expenses from the primary plan and enter them into the calculator.

3. Select the Secondary Plans Benefit type, enter secondary copays, and select calculate to determine the COB amount.

• For contact lenses, providers can refer to the patient record report and enter the secondary contact lens allowance, except for MESSA.
• Uncheck the Exam for Total Plans. This will block the value for the exam, which is only available for Exam And plan.

4. The results section will summarize the Primary Plan's out of pocket, the eligible Secondary Allowances (based on the services checked to coordinate) and Payable amounts.

VSP will apply secondary allowances to similar services first. If any allowance remains, VSP will apply the amount to any other eligible services.

How do I determine primary versus secondary?

•  Please refer to the Coordination of Benefits section of the Provider Reference Manual.

 Which services can coordinate?

• The secondary plan may COB using only those services that were provided under the primary plan, as long as the patient is eligible for those services under the secondary plan. For example, if the patient receives exam and lenses, the secondary plan can only COB the exam and lens services, if eligible.
• Secondary allowances are cumulative. The value of the secondary plan's eligible services can be applied to all applicable services received on the primary plan.

How does the calculator know what the secondary allowances are?

•  The calculator has been designed with the secondary allowances for each service checked under “Service to Coordinate” section based on the VSP Secondary plan type.
• The calculator is not available for Allowance, Medicaid or secondary plans with another carrier.

How does the calculator know the patient's contact lens allowance for the Secondary plan?

• Since it varies by each group's plan, enter the Secondary Contact Lens Allowance for all plans, except if MESSA is the Secondary Plan (MESSA 1, 2, 3, 3+, Bronze/Silver/Gold or Platinum). Note: Effective 1/1/2021, MESSA Choice plans use the Choice Secondary Plan allowances, less copay.
• Enter the contact lens copay for the Secondary plan, if the client has one. This is not common. Do not include the Secondary plan’s copay for a covered contact lens exam.

VSP Signature Plan^®

Enrollment/Doctor Participation

All VSP doctors are part of the VSP Network.

COPAYS

Note: 

You may not waive copays.

Copays are indicated on the Patient Record Report when you receive an authorization. There are two types of copays:

• Exam and Materials: Separate copays are applied to the exam and to the materials.

Exam and Material copays are collected as the service is provided. For example, the exam copay will be collected when exam is performed, and the materials copay at the time materials are chosen.

• Total: A one-time copay is applied once per service frequency to exam or materials (glasses or visually necessary contact lenses).

A Total copay is collected in full as the exam and materials are provided. If all services are not provided on the first visit, collect the copay on the first visit and do not collect a copay for any subsequent visits during the same benefit period. Refer to the Patient Record Report to determine if/when copay applies.

Please do not split authorizations when the patient has a total copay unless necessary. If the authorization was split, please follow these guidelines:

• Refer to the Patient Record Report to determine if/when copay applies to the service being provided.
• If a patient receives an exam through one doctor and materials through another (either same office or different offices), the copay would apply to the first authorization requested. Refer to the Patient Record Report to determine if/when copay applies.

Note: 

In some cases, the copay may appear on both the exam and material authorizations when services are split. If this happens, VSP will only apply the copay to the first claim received. Be sure to check your explanation of payment. If a copay was collected from the patient and not applied by VSP, refund the patient the copay.

Covered comprehensive eye exams are generally available to patients once every 12 or 24 months on a service year, fiscal year, or calendar year basis. Provide the level of exam necessary to determine your patient’s eye health and visual status.

Patients may also be covered for:

• Essential Medical Eye Care services. For more information, see Essential Medical Eye Care in the VSP Manual.
• Retinal Screening. For more information about the Retinal Screening Value-Added Feature and Retinal Screening Covered Benefit, see Retinal Screening in the VSP Manual.

Your assigned VSP Signature Plan^® eye exam fees are based on levels of service. See Eye Exams in the VSP Manual for additional information. Exam services are paid only once per eligibility period. Don’t balance bill for exams.

Note:
Avoid reduced reimbursement. Bill separately for refraction (92015). Your Signature Network Fee Schedule lists your refraction fee.

Coverage typically includes necessary prescription lenses and a frame up to a client-specified wholesale/retail allowance, or an allowance toward contact lenses. Please review the Patient Record Report for complete coverage details before providing materials.

Patients are also eligible for established benefits on additional services and materials (see Value-Added Benefits, below).

Lenses

• Single vision, bifocal, trifocal, or lenticular lenses in glass or plastic.
• Eye sizes up to and including 60mm.
• Lined multifocal lenses in all segment widths, including occupational lenses. See the Dispensing & Patient Lens Enhancements section for specific details on occupational lenses.
• Prism and slab off.
• Base curves (regardless of curve).

Note: 

VSP only covers lenses that meet the minimum prescription criteria. Lenses that do not meet VSP’s minimum prescription criteria are considered to be plano lenses. Plano lenses, including plano sunwear, are not considered to be covered materials, unless the patient is eligible for such materials under their plan benefit coverage.

VSP’s minimum prescription criteria:
The combined power in any meridian is ±0.50 diopters or greater in at least one eye or one of the following exceptions occurs:
—Necessary prism of 0.50 diopters or greater in at least one eye
—Anisometropia is 0.50 diopters or greater in at least one eye
—Cylinder power is ±0.50 diopters or greater in at least one eye

If the patient chooses a lens enhancement not covered by the plan, charge the patient either the fee shown on the VSP Signature Plan Lens Enhancements Chart or your U&C fee, whichever is lower. (See Patient Lens Enhancements Fees Instructions for information on determining your U&C fee for lens enhancements.)

Frames

Note: 

VSP only covers frames when the lenses meet VSP’s minimum prescription criteria, unless the patient is eligible for plano lenses under their plan benefit coverage. Most VSP Signature Plan patients who’ve had laser correction surgery may use their frame benefit for plano sunglasses. Exclusions are noted in the Patient Record Report.

Under most VSP plans, your patient’s frame allowance is represented by a combination of the wholesale frame amount and corresponding retail amount for which your patient is covered. Although patients will only be informed of their retail allowance, they’re covered for any in-network (or covered) frame less than or equal to their wholesale or retail allowance. You receive your frame dispensing and the wholesale cost up to their wholesale allowance, plus collect any overage according to our frame overage procedures.

Note: 

Some patients have a covered in full frame allowance. For these plans, you receive your frame dispensing and the wholesale cost.

Most patients will have a minimum extra $20 on top of their frame allowance when they select Marchon^® or Altair^® frames. Look for the wholesale and retail allowances for Marchon/Altair and all other frames indicated on the Patient Record Report at authorization. You’ll be reimbursed based on the wholesale equivalent of the patient’s retail allowance for Marchon and Altair frames.

Your patient can apply the frame allowance to any frame, listed or unlisted, (except for out-of-network frames in which case the patient’s out-of-network frame allowance should be applied). If patients choose unlisted frames, use your acquisition cost instead of the Frames catalog price when submitting the “wholesale cost” to VSP.

There is no charge to patients for standard frame cases; however, you may charge patients for special orders or for deluxe frame cases.

VSP does not provide a dispensing fee when a patient-supplied frame is used and patients can’t be charged any additional fees.

Frame Overages

Charge the patient according to our frame overage procedures. When the selected frame exceeds both the wholesale and equivalent retail allowance coverage, your patient is responsible for the overages exceeding his or her retail frame allowance at 80% of U&C. Don’t charge your patient more than 80% of U&C on frame overage, plus any applicable sales tax.

For more information, refer to the Providing Frames section in the VSP Manual.

Contact Lenses

Many clients provide coverage for contact lenses in lieu of prescription glasses. To be eligible for contact lens coverage, a patient must usually first be eligible for eyeglasses. Refer to the Contact Lens Benefits in this section.

Lab

The VSP Signature Plan does not cover fabrication or supply of lenses from your office. Covered lenses dispensed to VSP patients must be fabricated entirely by a participating VSP Lab or VSP contract lab (unless you are providing a Doctor In-Office Lens Enhancements or there is an emergency).

• You may bill WellVision Exams^® using S0620 (routine ophthalmological examination, including refraction, new patient) or S0621 (routine ophthalmological examination, including refraction, established patient). Be sure to complete a comprehensive exam when using these codes, VSP pays at the comprehensive level.
• If you choose to use 920XX codes to bill your WellVision Exams, please remember to bill refraction (92015) separately for accurate reimbursement.
• WellVision^® Exams should be billed with the appropriate refractive error diagnosis code. Reasons for encounters diagnosis codes are also acceptable.
• Reasons for encounters diagnosis codes are payable for WellVision^® Exams only. Reasons for encounters diagnosis codes may not be billed as primary or as the sole diagnosis code for materials.
• Materials must be billed with the appropriate refractive error diagnosis code.
• Enter additional diagnosis codes if other medical conditions exist.
• Bill non-covered materials on a private invoice, even if a VSP contract lab is used. Non-covered lenses may be fabricated at any lab of your choice, including in-office labs.
• When billing progressive lenses remember to bill your U&C fee on two lines, one for the base bifocal lenses and the second for the progressive add-on.

For Post-Lasik patients only: When billing plano sunglasses for VSP Signature Plan members:

• Bill as frame only (don’t include lenses). The patient is responsible for the cost of lab supplied plano lenses and lens enhancements.
• Indicate “frame only” in the box.
•  Document your patient’s LVC history in their medical file.

The Value-Added benefits* below are considered a private transaction between you and the patient. The patient is fully responsible for the payment of any additional items.

Exam Services

Deduct 20% on additional eye exams, including if only a refraction is performed.

Materials

Under the VSP Signature Plan, patients are eligible for additional materials at 70% U&C when they purchase a complete pair of prescription or non-prescription glasses/sunglasses, on the same day as their eye exam from your office. If a patient purchases a complete pair of prescription or non-prescription glasses/sunglasses, within 12 months of the exam, charge 80% of U&C. This includes proprietary lenses and frame, plano sunglasses, and non-prescription ready-made blue light filtering glasses.

For all other plans, charge 80% of U&C for additional materials when complete pairs of prescription, or non-prescription glasses, plano sunglasses, or non-prescription ready-made blue light filtering glasses are dispensed within 12 months of the exam. Includes proprietary lenses and frame, plano sunglasses, and non-prescription ready-made blue light filtering glasses.

Benefits should:

• be based on your total U&C fee,
• be unlimited for 12 months on or following the date of the last covered eye exam,
• be available through a VSP Network Doctor. Use professional judgment when evaluating prescriptions from another provider. You may request an additional exam at 80% of your U&C fee,
• apply to prescription and non-prescription lenses,
• not apply to cleaning products or repairs of prescription lenses or frames.

Note: 

If eligible for lens only or frame only and a complete pair of glasses is purchased, charge 80% of U&C for the non-covered material.

Contact Lens Service Benefit

Charge 85% of U&C on all elective, and replacement contact lens services. The benefit:

• is subtracted from your U&C fee for evaluation/fitting services;
• is unlimited for 12 months on or following the date of the covered eye exam;
• is available only through a VSP Network Doctor. Use professional judgment when evaluating prescriptions from another provider. You may request an additional exam at 80% of your U&C fee;
• does not apply to materials, solutions, cleaning products, and service agreements.

VSP Laser VisionCare^SM Program

• The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using microkeratome, Custom PRK, or Bladeless LASIK.
• Members receive a complimentary screening as well as preoperative and postoperative services through participating VSP network doctors. Most VSP Signature Plan patients who’ve had laser correction surgery can use their frame benefit for plano sunglasses.
• If the laser center is offering a temporary price reduction, VSP members will receive 5% off the advertised price if it is less than the usual discount price.
• Please see the Laser VisionCare Program section under Programs on VSPOnline for information on how to participate or for a list of participating facilities.

*VSP does not require providers to provide discounts on non-covered services in states where it’s prohibited by law to require it. However, unless you’ve opted out, you should continue to provide all Value Added Benefits to all VSP members. For more information, including details regarding how to opt out, call VSP at 800.615.1883.

Refractive Error Diagnosis Codes

Reasons for Encounters Diagnosis Codes

Reasons for encounters diagnosis codes are payable for WellVision^® Exams only. Reasons for encounters diagnosis codes may not be billed as primary or as the sole diagnosis code for materials.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Contact Lens Benefits

VSP patients may have the following contact lens benefits:

• Contact Lens Exam Copay with Materials Allowance: The routine eye exam is covered separately. Your patient has a not-to-exceed patient copay for a contact lens exam (prescription and fitting of contact lens) and a separate allowance for contact lens materials.
• Exam And (Combined Contact Lens Allowance): The routine eye exam is covered separately. Your patient has a combined allowance for a contact lens exam and materials.
• Total Allowance: Your patient has a single allowance for the routine eye exam, contact lens exam, and materials.
• Visually Necessary Contact Lenses: With an approved diagnosis or condition, your patient is covered for a contact lens exam and an annual supply of visually necessary contact lenses. See Visually Necessary Contact Lenses in this section for specific benefit coverage criteria.
• Covered Contact Lenses: Your patient is covered for a contact lens exam and an annual supply of contact lenses.

Note: 

For Visually Necessary Contact Lenses and Covered Contact Lenses, VSP will only cover an annual supply of materials based on the manufacturer’s replacement schedule. No additional reimbursement for Visually Necessary Contact Lenses and Covered Contact Lenses shall be reimbursed by VSP through additional VSP plans/coverage the patient may have.
You may only coordinate benefits up to the annual supply of contact lens materials if plans permit. See Coordination of Benefits Between Multiple VSP^® Plans in the VSP Manual.
Visually Necessary Contact Lenses and Covered Contact Lenses include the contact lens exam services and an annual supply of contact lens materials. Bill contact lens exam services with materials.

A contact lens exam (prescription and fitting of contact lens) is separate from the WellVision Exam^® and should be provided only to patients who wear or want to wear contact lenses and specifically request a contact lens exam. Contact lens insertion and removal training services are not separately reimbursed.

Note: 

The “initial” contact lens fitting period for all contact lens benefits is 90 days. Any additional or excluded (i.e., CRT, Ortho-K and myopia management) contact lens fitting services should be handled privately between you and the patient.

You can find client-specific exceptions in the special comments section of the Patient Record Report.

Contact Lens Exam Copay with Materials Allowance: Your patient pays an exam copay if you provide a WellVision Exam. Patients who request a contact lens exam pay a contact lens exam copay or 85% of your U&C fees, whichever is less. There is no copay for contact lens materials, which are covered under a separate allowance.

Exam And (Combined Contact Lens Allowance): Patient pays an exam copay if you provide a WellVision Exam. There is no copay for contact lens materials.

Total Allowance: No exam or materials copay is required if materials are purchased on the same date of service. The exam copay may apply if the WellVision Exam is given on a different date of service.

Covered Contact Lenses: Your patient pays the contact lens copay.

VSP covers contact lenses that meet the minimum prescription criteria. Contact lenses that do not meet VSP’s minimum prescription criteria are considered to be plano lenses.

VSP’s minimum prescription criteria:
The combined power in any meridian is ±0.50 diopters or greater in at least one eye or one of the following exceptions occurs:
—Necessary prism of 0.50 diopters or greater in at least one eye
—Anisometropia is +0.50 diopters or greater in at least one eye
—Cylinder power is ±0.50 diopters or greater in at least one eye

Exclusions

Some materials aren’t covered under VSP’s contact lens benefits. There are no benefits for professional services or materials connected with the following:

• Corneal refractive therapy, orthokeratology, and contact lenses for myopia management are not covered under Visually Necessary Contact Lenses, Covered Contact Lenses, or the VSP Elements Plan. Patients can use their elective contact lenses allowance towards the cost of corneal refractive therapy, orthokeratology, or myopia management contact lens materials only. The contact lens fitting and evaluation portion of the treatment is a private transaction between you and the patient.
• Replacement of lost or damaged lenses
• Modifications of lenses
• Routine maintenance such as polishing, cleaning, etc.
• Refitting after the initial (90-day) fitting period
• Insurance policies or service agreements
• Plano (non-prescription) lenses or lenses that don’t meet our minimum prescription requirement
• Plano lenses to change eye color cosmetically
• Office visits to treat contact lens pathology
• Solutions and other contact lens supplies
• Bandage contact lenses aren’t covered under VSP^® plans but can be submitted under Essential Medical Eye Care for eligible patients. See Essential Medical Eye Care in this section.

A visually necessary contact lens exam and an annual supply of visually necessary contact lenses are covered in full for patients meeting the established conditions and requirements below. Those patients must be eligible for materials on the date of service. Coverage is limited and may require special handling to ensure proper reimbursement. Exam and material copays for contact lenses apply unless otherwise specified.

Note: 

Visually necessary contact lenses aren’t typically covered for patients who have received refractive surgery (e.g., LASIK, PRK, or RK). However, patients with underlying conditions such as corneal, ectasia, corneal deformity, scarring or irregularity that require contact lenses to provide vision improvement, may be covered for visually necessary contact lenses, if they meet the approved criteria. Treatment for corneal abrasion is covered under Essential Medical Eye Care.

• Nystagmus – H55.00 through H55.09
• Anisometropia greater than or equal to 3.00 diopters difference in any meridian based on the spectacle prescription.
• High ametropia in either eye greater than or equal to ±10.00 diopters in any meridian based on the spectacle prescription.
• Please see Visually Necessary Specialty Contact Lenses below for a complete listing of covered diagnosis codes.

Note:

Patients meeting criteria for nystagmus, anisometropia or high ametropia do not require an improvement in best corrected visual acuity (BCVA) by two lines compared to spectacles.

• Achromatopsia – H53.51
• Albinism – E70.30, E70.310, E70.311, E70.318, E70.319 
• Aniridia – Q13.1
• Polycoria; anisocoria (congenital) – Q13.0
• Pupillary abnormalities – H21.561 through H21.569

Note:

Patients meeting criteria for colored contact lens do not require an improvement in best corrected visual acuity (BCVA) by two lines compared to spectacles.

To submit visually necessary contact lens claims through eClaim for any of the conditions above, do the following:

Select Necessary Contact Lens as the Contact Lens Reason. Indicate the appropriate diagnosis code and/or spectacle prescription verifying the condition. For anisometropia and/or high ametropia, enter the spectacle prescription on the lab invoice for verification purposes. Not all conditions can be verified on Eyefinity. See Submitting Claims for additional instructions.

Scleral Lenses (For Covered Contacts and Visually Necessary Contacts)

Bill scleral lenses using HCPCS V2530 or V2531. Hybrid contact lenses are not scleral lenses and will not be reimbursed as sclerals. Bill hybrid lenses using V2599.

When submitting a claim for Visually Necessary Contacts using V2531, you must provide the following information in Box 19:

• Type of lens – Scleral
• The scleral lens manufacturer or brand

If this information is missing or incomplete, it will result in claim reimbursement at the V2599 rate.

Other Type of Contact Lenses (For Covered Contacts and Visually Necessary Contacts)

Use HCPCS code V2599 for other types of contact lenses, such as hybrid lenses.

When submitting a claim using V2599 (contact lens, other type) you must provide the following information in Box 19:

• Type of lens
• The lens manufacturer or brand
• For example, hybrid contact lens, SynergEyes^® iD

If the information is missing or incomplete, it will result in claim reimbursement at the V2510 rate.

Note: 

Bill scleral lenses using HCPCS V2530 or V2531. Hybrid contact lenses are not scleral lenses and will not be reimbursed as scleral.

Piggyback Lenses Benefit

Piggyback lenses are a covered benefit for patients meeting one of the conditions above, and who aren’t able to tolerate rigid gas permeable contact lenses. This requires the use of soft contact lenses and rigid gas permeable contact lenses, in the manner of a piggyback fitting.

When submitting a claim for piggyback lenses, you must provide the following information in Box 19:

• Piggyback lenses

Spectacle lenses to wear over contacts benefit

Contacts with spectacle lenses to wear over contacts are covered benefits for patients with the following conditions:

• Aphakia – H27.01 - H27.03 or Q12.3
• High ametropia greater than or equal to ±10.00 diopters in either eye based on the spectacle prescription.
• Presbyopia – H52.4
• Pseudophakia – Z96.1
• Accommodative disorder
• Binocular function disorder
• Different prism requirements for distance and near vision

A prescription is required for the lenses. Plano lenses aren’t a covered benefit.

When your patient qualifies for spectacle lenses to be worn over contact lenses, request the spectacle lenses claim number at the same time or within 30 days of the contact lens claim submission date. For patients with keratoconus, request a claim number for spectacle lenses to be worn over contact lenses within 12 months of the contact lens claim submission date. Frames are private transaction between you and your patient.

If your patient meets the benefit criteria for visually necessary contact lenses above and also requires spectacle lenses to wear over the contacts, please verify that the above criteria is met, and call VSP at 800.615.1883 to obtain a claim number. Please have the relevant criteria information available when calling.

Submitting Claims

Request a case number when your patient meets the benefit coverage criteria above, but you can’t submit your claim through eClaim at eyefinity.com. To get a case number so you can submit your claim through eClaim, complete a Materials Verification Form, which must include at least one of the qualifying criteria listed above. Please allow five (5) business days for a response. Put your case number in Box 23.

The following situations also require the submittal of a Materials Verification Form:

• NCL claims with DOS over 6 months
• Physical condition of ears or nose which prohibits the use of eyeglasses
• Physical symptoms associated with paraplegia or quadriplegia (be specific)

Fax the Materials Verification Form to us at 916.851.4733. Or mail to VSP, PO Box 495907, Cincinnati, OH 45249-5907. You can find the form in the VSPOnline section of eyefinity.com or in the Tools and Forms section of this manual.

Reimbursement for Visually Necessary Contact Lenses and Covered Contact Lenses

An annual supply of contact lenses is covered in full for patients. Visually Necessary Contact Lenses must meet the stated benefit criteria. We’ll reimburse you:

• Your assigned fee for the examination
• Up to allowed amount for the type and quantity of contacts provided (Maximum allowed amount applies to the combination of 85% of your U&C fee for the contact lens exam and your U&C fee for contact lens materials)

Do not balance bill your patient the difference between VSP’s allowed amounts and your U&C fee for materials. Exam and material (spectacle lenses and frame) copays apply unless otherwise specified. Any contact lens fitting fees incurred after the initial 90 day period are considered a private matter between you and the patient. Do not submit a separate claim for a contact lens exam.

Note: 

Fees submitted to VSP for all contact lens plan benefits must be consistent with your U&C charges, regardless of the patient’s coverage or allowances.

¹Annual Replacement is 1-2 units. Planned Replacement is 3-360 units. Daily Replacement is 361+ units.

*These services shouldn’t be billed for more than 2 units. If billed with higher unit counts, we’ll pay up to the Annual Replacement lens maximum. Refer to billing instructions for scleral lenses above.

**These services shouldn’t be billed for more than 360 units. If billed with higher unit counts, we’ll pay up to the Planned Replacement lens maximum. Refer to billing instructions for hybrid and proprietary lenses above.

Benefit Coverage Criteria for Visually Necessary Specialty Contact Lenses

Beginning June 1, 2024, an improvement in best corrected visual acuity (BCVA) by two lines compared to spectacles is required for Visually Necessary Contact Lenses specialty conditions. BCVA findings for specialty conditions must be recorded on the patient’s medical exam records and demonstrate a two-line improvement compared to spectacles and are subject to review and audit. Conditions notated with “**” are excluded from the BCVA requirement.

If billing with CPT code 92072*, 92310* 92311*, 92312* or 92313* – for one of these diagnosis codes:

*Codes may not be billed together on the same claim.

** Condition does not require an improvement in best corrected visual acuity (BCVA) by two lines compared to spectacles.

Note: 

To substantiate billing for keratoconus, your records must include: patient history; K readings; BCVA with refraction; slit lamp examination of the cornea; corneal topography or anterior OCT of the cornea.

Visually Necessary Contact Lens Specialty Maximums

¹Annual Replacement is 1-2 units. Planned Replacement is 3-360 units. Daily Replacement is 361+ units.

*These services shouldn’t be billed for more than 2 units. If billed with higher unit counts, we’ll pay up to the Annual Replacement lens maximum.

**These services shouldn’t be billed for more than 360 units. If billed with higher unit counts, we’ll pay up to the Planned Replacement lens maximum.

Submitting the Claim

Important! 

Global fees are not appropriate. Fees must be itemized and include separate charges for contact lens exam and materials. You must bill for both the contact lens exam and materials, to be reimbursed.

Important!

DO NOT BILL VSP FOR PROFESSIONAL SERVICES ASSOCIATED WITH CRT, ORTHO-K OR MYOPIA MANAGEMENT.

Reimbursement

Important! 

Determine your U&C fees for a contact lens exam, then add taxes if applicable (see chart below). Bill this amount on the claim. Follow your state tax guidelines.

New Mexico doctors: Determine your total fees for services and materials. Bill this amount on the claim.

Note: 

Failure to record your contact lens exams, fittings and follow-ups may result in the denial of payment for services.
Ensure that your medical records accurately support the diagnosis submitted on the claim when billing for Visually Necessary Contact Lenses. By doing so your payment will not be denied if the diagnosis billed is substantiated by the clinical findings documented in the patient’s record.

See Contact Lens Case Management Procedures for contact lens fitting documentation criteria.

VSP Access Plan^® & VSP Access Indemnity Plan^SM

VSP’s Access Plan is a vision savings program on an eye exam and eyewear through a VSP network provider. The Access Indemnity Plan combines the Access Plan with an indemnity schedule of allowances, established by the client.

Eligibility & Authorization

Eligibility can be obtained on eyefinity.com or by calling VSP at 800.615.1883.

Exam Services

• Patients are eligible for eye exams, including if only a refraction is performed at 80% of U&C.
• Coverage only applies to services and procedures included in a WellVision^® Exam. It doesn’t apply to additional diagnoses and treatment.

Materials

Charge patients 80% of U&C for frames, lenses, and lens enhancements when a complete pair of prescription glasses or non-prescription sunglasses is dispensed. The benefit:

• Is unlimited for 12 months on or following the date of an eye exam from a VSP doctor.
• Doesn’t apply to cleaning products or repairs of prescription lenses or frames.

When dispensing materials, use professional judgment in evaluating prescriptions from another doctor. If necessary, you can request additional routine exams at 80% of U&C

Contact Lens Services

Charge patients 85% of U&C for contact lens exam services (F&E) and follow-up services. The benefit:

• Applies to services for prescription contact lenses only.
• Is unlimited for 12 months on or following the date of an eye exam from a VSP Network Doctor.
• Doesn't apply to contact lens materials, solutions, cleaning products or service agreements.

The benefits are considered a private transaction between you and your patient; your patient is responsible for paying for the services or materials.

VSP Laser VisionCare^SM Program

• The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using the microkeratome, Custom PRK, or Bladeless LASIK.
• Members receive a complimentary screening as well as preoperative, and postoperative services through participating VSP doctors.
• If the laser center is offering a temporary price reduction, VSP members will get 5% off the advertised price if that’s less than the usual discount price.
• Please see the Laser VisionCare section under Programs on VSPOnline on eyefinity.com for information on how to participate or for a list of participating facilities.

Eligibility & Authorization

Eligibility can be obtained on eyefinity.com or by calling VSP at 800.615.1883.

Allowances are paid by us only once during each eligibility period, unless authorization indicates banking or banking with multiple services. 

Exam Coverage

• Patients are eligible for an eye exam and additional eye exams, including if only a refraction is performed at 80% of U&C.
• Coverage only applies to services and procedures included in an eye exam. It doesn't apply to additional diagnoses and treatment.
• Deduct 20% from the exam first, then apply the allowance.

Materials Coverage

Patients are eligible for prescription lens, lens enhancements and/or frame (complete pair not required) at 80% of U&C, plus a group-specific schedule of allowances. The benefit:

• Is unlimited for 12 months on or following the date of the last covered eye exam.
• Doesn't apply to cleaning products or repairs of prescription lenses or frames.
• Deduct 20% from the materials first, then apply the allowance.

When dispensing materials, use professional judgment in evaluating prescriptions from another doctor. If necessary, you can request additional routine exams at 80% of U&C

Contact Lenses Services & Materials

Patients are eligible for contact lens exam services (evaluation/fitting services and follow-up services) at 85% of U&C. You may charge your U&C fees for contact lens materials. Elective or visually necessary contact lenses are chosen in place of a complete pair of prescription glasses. You may bill the patient for any fees over the allowance and any applicable copay amount. The benefit:

• Applies to services for prescription contact lenses only.
• Is unlimited for 12 months on or following the date of the last covered eye exam, however the allowance schedule apples only once.
• Use professional judgment when evaluating prescriptions from another doctor.
• Doesn't apply to contact lens materials, solutions, cleaning products or service agreements.
• Deduct 15% from contact lens exam services (F&E) charge, then add your U&C fees for contact lens materials and apply the allowance.

When dispensing materials, use professional judgment in evaluating prescriptions from another doctor. If necessary, you can request additional routine exams at 80% of U&C.

Lab

Lab work is handled privately. You may provide lenses through any lab, including in-office labs.

Value-Added Benefits

The value-added benefits below are considered a private transaction between you and your patient; your patient must pay for any additional items:

• Patients are eligible for additional complete pairs of prescription glasses or non-prescription sunglasses and blue light filtering glasses, from any VSP doctor within 12 months of the last eye exam at 80% of U&C. The benefit:
  • Is based on your total U&C fee.
  • Is unlimited for 12 months on or following the date of the last covered eye exam.
  • Use professional judgment when evaluating prescriptions from another doctor.
  • You can request an additional routine exam at 80% of U&C.
  • Doesn't apply to cleaning products or repairs of prescription lenses or frames.
• Patients are eligible for contact lens exam services (evaluation/fitting services and follow-up services) at 85% of U&C. The benefit:
  • Is based on your total U&C fee.
  • Applies to services for prescription contact lenses only.
  • Is unlimited for 12 months on or following the date of the last covered eye exam.
  • Use professional judgment when evaluating prescriptions from another doctor.
  • Doesn't apply to solutions, cleaning products or service agreements.

VSP Laser VisionCare^SM Program

• The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using the microkeratome, Custom PRK, or Bladeless LASIK.
• Members receive a complimentary screening as well as preoperative, and postoperative services through participating VSP doctors.
• If the laser center is offering a temporary price reduction, VSP members will get 5% off the advertised price if that's less than the usual discount price.

VSP Access Plan^®

Apply the VSP Access Plan vision savings, as follows: exam at 80% of U&C; glasses at80% of U&C; contact lens exam at 85% of U&C. Handle the visit as a private pay transaction. Don’t submit a claim to VSP. Collect the appropriate fees from the patient.

VSP Access Indemnity Plan^SM

• Apply the vision savings noted above for VSP Access Plan to your U&C professional fees.
• Subtract your patient’s Access Indemnity Plan allowance (found on the Patient Record Report) from adjusted U&C fees.
• Bill your patient for the difference between your adjusted U&C fees and the indemnity allowance.
• Bill VSP for services.
• Your patients may use their benefits for prescription glasses (lens and/or frame) or contact lens fitting/materials.
• For your patients with combined allowances without banking or banking with multiple services, bill all services at the same time so your patients get their full benefits.

Glasses: Bill using eClaim.

• Complete the Invoice Services page and select “Non-VSP lab (Private Invoice).”
• Click on the “Calculate HCPCS and Continue” button.
• Complete the Diagnosis and Services page by entering your full U&C fees next to the appropriate CPT/HCPCS code.

Contact Lenses: Bill using eClaim.

• Choose the type of contacts dispensed.
• Click on the “Calculate HCPCS and Continue” button.
• Complete the Diagnosis and Services page by entering your full U&C fees next to the appropriate CPT/HCPCS code.
• Please see the Necessary Contact Lens Benefit Criteria section of your VSP Provider Reference Manual for more information regarding benefit criteria and claim submission.

Following is an example of an exam, prescription lenses and frame provided under the VSP Access Indemnity Plan. The indicated U&C fees and indemnity allowance amounts are examples only.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

VSP Integrated Primary EyeCare Program^SM

The Integrated Primary EyeCare Program lets VSP network doctors work directly with VSP’s health plan clients to obtain eligibility, authorizations, and submit claims for medical eyecare. The program is an addition to the VSP medical product portfolio that supports the ability of all VSP network doctors to practice to their full scope of licensure.

Through Integrated Primary EyeCare, enrollees of VSP-contracted health plan clients will gain access to VSP network doctors. At the time a health plan client contracts with VSP to provide this program in your area, you will be provided with specific health plan client information, including the negotiated reimbursement rate.

Enrollment will be automatic for each network in which a doctor participates (e.g., VSP, Select, Advantage, Choice, and Medicaid). Integrated Primary EyeCare patients can only be referred to another doctor or refused service, if you’re not licensed to perform the service needed.

To render services through this program, VSP network doctors agree to:

• Maintain an active status with VSP.
• Follow each health plan client’s policies and procedures relating to the delivery of medical eyecare.
• Be listed in the health plan’s provider directory.
• Accept compensation that is based on a percentage of the Medicare or Medicaid fee schedule for your locality and/or state, and which may vary by client. (See Client Details pages of the VSP Provider Reference Manual for specific details.)
• See all eligible members of VSP-contracted health plan clients.
• Submit Integrated Primary EyeCare claims to the patient’s health plan carrier, not to VSP.
• Accept payment for services under the program from the patient’s health plan carrier or its administrative services provider, not VSP.
• Accept payment, less any copays or coinsurance by the VSP-contracted health plan client, as payment in full for services covered under the Integrated Primary EyeCare Program.
• Submit all complaints and grievances regarding Integrated Primary EyeCare patients and claims to the health plan client, and hold VSP harmless from such complaints and grievances.

Please refer to Client Details for additional information.

Compensation is based on a percentage of either the Medicare RBRVS allowables for your location or the state Medicaid fee schedule. VSP will negotiate the reimbursement rate with the health plan client on the doctors’ behalf. Each client contract requires clients to follow state and federal guidelines when paying doctors.

VSP Exam Plus Plan^SM and VSP Exam Plus with Allowances Plan^SM

Exam Coverage

Exam Plus patients are covered for a comprehensive eye exam.

Materials

The benefits below are considered a private transaction between you and your patient. Your patient must pay for any additional items.

• Patients are eligible for complete sets of prescription glasses or non-prescription sunglasses from a VSP doctor within 12 months of the last eye exam at 80% of U&C. The benefit:
• Patients are eligible for contact lens exam services (F&E) and follow-up services at 85% U&C. The benefit:
• Is unlimited for 12 months on or following the date of the last eye exam.
• Use professional judgment when evaluating prescriptions from another doctor. You can request an additional routine exam at 80% of U&C.
• Deduct 20% on additional eye exams, including if only a refraction is performed.
• Doesn’t apply to cleaning products or repairs of prescription lenses or frames.
• Applies to services for prescription lenses only.
• Doesn’t apply to contact lens materials, solutions, cleaning products, or service agreement

Exam Coverage

VSP Exam Plus With Allowance patients are covered for a comprehensive eye exam.

Materials Coverage

Lenses and Frames

Patients are eligible for prescription lens, lens enhancements and/or frame (complete pair not required), plus they have a group-specific schedule of allowances. The lens allowance is applied to the complete lens service—including both the base lens and any lens enhancements selected.

VSP only covers frames that are used for prescription lenses that meet VSP’s minimum prescription criteria (refractive error is at least +/- 0.50 diopter), unless the patient has plano coverage.

The benefit is available for 12 months on or following the date of the last covered eye exam. Deduct 20% from the materials first, then apply the allowance.

Contact Lenses

Charge patients with Elective Contact Lens (ECL) or Visually Necessary Contact Lens (NCL) coverage 85% U&C for contact lens exam services (evaluation/fitting services and follow-up services). You may charge your U&C fees for contact lens materials. Elective or visually necessary contact lenses are chosen in place of a complete set of prescription glasses. Your patient must pay any costs over the allowances listed in their client-specific schedule of allowances.

Lab

Lab work is handled privately. You may provide lenses through any lab, including in-office labs.

Value-Added Benefits

The Value-Added benefits below are considered a private transaction between you and your patient. Your patient must pay for any additional items.

• Patients are eligible for additional complete pairs of prescription glasses and non-prescription sunglasses and blue light filtering glasses, from any VSP doctor within 12 months of the last eye exam at 80% of U&C. The benefit:
  • Is unlimited for 12 months on or following the date of the last eye exam.
  • Use professional judgment when evaluating prescriptions from another doctor. You can request an additional routine exam at 80% of U&C.
  • Deduct 20% on additional eye exams, including if only a refraction is performed.
  • Doesn’t apply to cleaning products or repairs of prescription lenses or frames.
• Patients are eligible for contact lens exam services (F&E) and follow-up services at 85% of U&C. The benefit:
  • Applies to services for prescription lenses only.
  • Is unlimited for 12 months on or following the date of the last eye exam.
  • Use professional judgment when evaluating prescriptions from another doctor.
  • Doesn’t apply to contact lens materials, solutions, cleaning products, or service agreements.

Submitting Claims/Billing & Reimbursement

VSP Exam Plus With Allowances

• Your patient pays the amount above their allowance. You may charge your U&C fees for contact lens materials. Progressive lenses are reimbursed at the bifocal allowance.
• For patients with combined allowances without banking or banking with multiple services, bill all services at the same time so your patients get their full benefits. Remaining allowances can’t be carried forward. The combined allowance applies to only one set of services. Your patients may use their benefits for a complete pair of prescription glasses or contact lens fitting/materials.

Submitting the Claim Electronically

Glasses:

Bill using our electronic claims submission system.

• Complete the Invoice Services page and select Non-VSP lab (Private Invoice).
• Click on the Calculate HCPCS and Continue button.
• Complete the Diagnosis and Services page by entering your full U&C fees next to the appropriate CPT/HCPCS code.

Contact Lenses:

Bill using our electronic claims submission system.

• Choose the type of contacts dispensed.
• If contact lens evaluation/fitting services were provided, show this in the dropdown.
• Click on the Calculate HCPCS and Continue button.
• Complete the Diagnosis and Services page by entering your full U&C fees next to the appropriate CPT/HCPCS code.
• Please see the Necessary Contact Lens Benefit Criteria section of your VSP Provider Reference Manual for more information regarding benefit criteria and claim submission.

Submitting the Claim on Paper

Glasses:

• Enter your full U&C fees next to the right CPT/HCPCS code.
• Complete the CMS-1500 Claim Form by entering your full U&C fees next to the right CPT/HCPCS code for lens and frame.
• Enter all eight digits of the authorization number in Box 23.

Contact Lenses

• Enter your full U&C fees next to the right CPT/HCPCS code.
• Select the type of contacts dispensed.
• Enter all eight digits of the authorization number in Box 23.

• The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using microkeratome, Custom PRK, or Bladeless LASIK.
•  Members receive a complimentary screening as well as pre-operative and post-operative services through participating VSP doctors.
• If the laser center is offering a temporary price reduction, VSP members will get 5% off the advertised price if that’s less than the usual discount price.
• Please see the Laser VisionCare page under Programs on VSPOnline at eyefinity.com for information on how to participate or for a list of participating facilities.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

ProTec Safety^® Plan

The ProTec Safety Plan provides a range of hazardous work environment coverage options for clients and members. With ProTec Safety, your patients can see you for their safety eyewear needs, which provide continuity of care for your patients.

Safety Requirements Questionnaire

ProTec Safety patients should complete a questionnaire about their work environments and related safety requirements before receiving safety services. You can use VSP’s Safety Requirements Questionnaire if you’d like or one you’ve created. Keep a copy of the completed questionnaire in your patients’ record.

Coordination of Benefits

There’s no coordination of benefits under the ProTec Safety plan.

ProTec Safety patients may have routine VSP coverage that covers their routine exam where work safety needs may be additionally addressed, as appropriate. Please refer to the Patient Record Report for exam coverage and benefit information because your patients may have different coverage.

If a patient would like their safety prescription filled, it must be under two years old. Additionally, you can choose to require a new exam prior to providing materials based on your professional judgment. If you decide that an exam is necessary and the patient’s exam is not covered through their routine benefit or they do not have supplemental exam coverage under their ProTec Safety Plan, deduct 20% from the usual and customary (U&C) exam fee.

Necessary corrective lenses (i.e. single vision, bifocal, trifocal, or lenticular) in glass or plastic (CR-39) that meet the American National Standards Institute (ANSI) standards are detailed below for safety eyewear.

ANSI Requirements

The lenses and frames provided under this plan are certified as safe for the work environment by meeting the necessary requirements set forth by ANSI effective April 20, 2020.

Lenses

Covered Lens Enhancements

Covered lens enhancements are available and will vary depending on the patient’s benefit. VSP will pay the lab for any covered lens enhancement and there’s no charge to the patient. Refer to the Patient Record Report for lens enhancement coverage. In most cases, ProTec Safety patients will be covered for polycarbonate lenses.

Other Enhancements

If your patient selects a lens enhancement that is covered with copay, charge the patient your usual and customary fee (U&C) for the lens enhancement or their lens enhancement copay. (refer to the VSP Signature Plan Lens Enhancement Chart), whichever is lower. Refer to the Patient Record Report for lens enhancement coverage.

Non-covered Items

These options and items aren’t covered under the ProTec Safety plan and VSP will deny the claim if submitted for reimbursement:

• Contact lenses
• Everyday eyewear instead of safety materials
• Materials obtained from a non-VSP doctor, unless the group has out-of-network coverage
• Plano or non-prescription lenses, unless otherwise indicated on the Patient Record Report (minimum prescription ±0.50 diopters required for lenses)

Frames

Covered Frames

ProTec Safety patients can choose one of the 30 ANSI-approved frames from the ProTec Eyewear collection. Some member plans have a frame benefit that allows for choice of a ProTect Frame Retail Frame Allowance to use towards any Safety Rated frame outside of the ProTec Eyewear collection. These plans will have the detailed information on the Patient Record Report with the wholesale and retail allowances for the plan. ProTec Eyewear frames from the collection are fully-covered for the patient and will be supplied by a participating lab (see the Lab section for more details). Depending on the patient’s frame allowance, if the patient chooses a frame outside of the ProTec Eyewear collection, overages should be determined using the VSP Signature Plan frame overage policy. If the patient does not have a retail frame allowance as part of their benefit, the patient must select a frame from the ProTec Eyewear collection or online catalog.

Non-Covered Frames

For patients that do not have a retail frame allowance and are required to select from the ProTec Eyewear collection and one of the following occurs:

• The needed eye size isn’t available in any of the covered frames
• None of the frames meets the hazardous work environment of your patient.
• The patient has an allergy to the standard safety frame materials used in the covered frames.

The non-ProTec Eyewear frame is not covered in full and you must submit a ProTec Safety Verification Form to document the exception. Once the exception is documented, then the patient will have a retail frame allowance of $65 (wholesale of $25). If the member chooses a frame with a cost that exceeds both the wholesale and retail allowances, deduct 20% from the retail overage. Determine the patient’s cost (if any) as you do today and collect any overages from the patient.

Important! 

You must submit a ProTec Safety^® Verification Form to VSP to document the exception. Only use if the member plan does not have a Retail Frame Allowance. 

Additional Materials

When a complete pair of glasses, including plano sunglasses, is dispensed within 12 months from the date of the last eye exam, charge the patient 80% of U&C for non-covered materials. Refer to the Value-Added Benefits in the VSP Signature Plan^® section for details.

All ProTec Safety orders must be sent to a participating lab:

VSPOne Columbus
800.251.5150
2065 Rohr Road, Lockbourne, OH 43137

When billing electronically, eClaim will only offer this lab choice for ProTec Safety orders. If you don’t already have an account with the lab, you may submit the order, but they may contact you for more information.

Paper claim practices: You must order lab-supplied materials from the participating labs listed above.

Emergency Situations

In emergencies, you can use any lab capable of producing ANSI certified safety eyewear (see the National Contract Lab List); choose lab 100 when billing on eClaim.

The following situations are considered emergencies. Include the reason for the emergency when submitting claims to VSP:

Use one of the following comments when indicating emergency status by selecting Lab Special Instructions:

• Patient’s safety glasses are lost, stolen, or broken and he or she doesn’t own a back-up pair.
• Patient needs safety glasses to work or drive, is unable to see well enough to do so, and doesn’t have a back-up pair of safety glasses.
• Patient’s safety and well-being will be jeopardized without the immediate delivery of his or her prescription safety eyewear.

Note: 

To obtain wholesale costs of ProTec Eyewear safety frames please see the Frame Data^® Price Book, available through Jobson, or contact the manufacturer directly for the list price.

Titmus at 855.848.6878
OnGuard (Hilco) at 800.955.6544
Wiley X at 800.776.7842

Refer to the Frame section for complete details and instructions on emergency situations.

Supplemental ProTec Safety Exams

The level of eye exam or the evaluation and management service that you provide depends on the location and the time elapsed since the patient’s last routine eye exam:

When possible, perform your supplemental and comprehensive or intermediate exams in the same visit.

*If you choose to use 920XX codes to bill your WellVision Exams, please remember to bill refraction (92015) separately for accurate reimbursement.

Stand-Alone ProTec Safety Plan Exams

Exams for Stand-Alone Safety EyeCare Plans are reimbursed at your Signature Plan comprehensive or intermediate exam payable fee.

Lenses

You’ll receive a flat rate dispensing fee of $25 for covered lenses. There are no additional reimbursements for dispensing progressive lenses or covered lens enhancements. Use CPT code 99022 (for shipping) when submitting for progressive lenses to be reimbursed up to the maximum allowable.

Frame

When patients choose a covered ProTec Eyewear frame, it will be supplied by a participating lab. You won’t receive a dispensing fee or material reimbursement for the frame. When submitting the claim, be sure to look for the Collection with ProTec next to it (i.e. Baseline Collection – ProTec) when entering frame information on EasyFind, or use the UPC number listed on the online catalog to select the appropriate ProTect frame.

Note: 

To obtain wholesale costs please see the Frame Data^® Price Book, available through Jobson, or contact the manufacturer directly for the list price.

Titmus at 855.848.6878
OnGuard (Hilco) at 800.955.6544
Wiley X, Inc. at 800.776.7842*

*If a patient that does not have the ProTec Safety Plan, is interested in a Wiley X, Inc. frame, you must contact Wiley X directly. Wiley X requires an account to be set up to sell their frames outside of the ProTec Safety Plan.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Safety EyeCare Plan

There are two types of Safety EyeCare plans: the Safety Supplemental Plan and the Safety Stand-Alone Plan. Most clients that provide safety benefits purchase the Safety Supplemental Plan, in addition to our VSP Signature Plan^®.

The Safety Stand-Alone Plan is similar to our Signature Plan, with two exceptions:

• Prescribed materials must meet American National Standards Institute (ANSI) standards for safety eyewear.
• Value-Added benefits don’t apply to non-covered materials.

Safety Requirements Questionnaire

Safety EyeCare Plan patients should fill out questionnaires about their work environments and related safety requirements before exams. A sample Safety Requirements Questionnaire is located in the Tools and Forms section of the Manuals on VSPOnline on eyefinity.com. Keep a copy of the questionnaire or the information it contains in your patient’s record.

Coordination of Benefits

There’s no coordination of benefits under most Safety EyeCare Plans.

When your patient has Safety Supplemental coverage, use the patient’s Signature Plan coverage for a routine eye exam and the Safety Supplemental Plan for supplemental exams. Give an intermediate or comprehensive eye exam under your patient’s Safety Supplemental Plan only if that patient isn’t eligible for an eye exam under the Signature Plan.

Necessary corrective lenses (i.e. single vision, bifocal, trifocal, or lenticular) in glass or plastic (CR-39) that meet the American National Standards Institute (ANSI) standards are detailed below for safety eyewear.

Certified safety eyewear, lenses and frames must meet the following standards set by ANSI, effective April 20, 2020:

Other Lens Enhancements

If your patient selects a lens enhancement that is covered with copay, . charge your patients the amount listed on the VSP Signature Plan Lens Enhancements Chart or your U&C, whichever is lower. Check the Patient Record Report.Examples of lens enhancements for patients:

Non-covered Items

The items below aren’t a benefit under the Safety EyeCare plan and VSP will deny the claim if submitted for reimbursement:

• Contact lenses
• Everyday eyewear instead of safety materials
• Materials obtained from a non-VSP doctor, unless the group has out-of-network coverage
• Plano (non-prescription) lenses (unless otherwise indicated)
• Rimless mounting

Frames

After determining patient eligibility and lens needs, have your patient choose a frame from your safety selection or the ProTec Eyewear^® online catalog. ProTec Eyewear offers ANSI Z87-2 certified frames in a variety of styles and colors, including Titanium and wrap-around. If your practice carries ProTec Eyewear, please note that the frames in the kit are for display purposes only. All ProTec Eyewear should be ordered through a participating lab and will be supplied by the lab.

Side shields and a frame case are included with ProTec Eyewear frames at no additional cost. If a client requires permanent side shields, a comment on the Patient Record Report will indicate the requirement.

Under the Safety EyeCare plan, patients can choose a frame with detachable or permanent side shields. If the frame and shields are priced separately, add the cost of the shields to the cost of the frame to determine the total cost. Depending upon the patient’s frame allowance, ProTec Eyewear frames may not be fully covered under the VSP Safety EyeCare Plan. Refer to the Patient Record Report for more information on the patient’s frame allowance. Overages should be determined using the VSP Signature Plan frame overage policy.

Note: 

If a patient with or without the VSP Safety Eyecare Plan is interested in a frame from the ProTec Eyewear kit, you’ll need the wholesale cost of the frame. To obtain wholesale costs please see the Frame Data^® Price Book, available through Jobson, or contact the manufacturer directly for the list price.

Titmus at 855.848.6878
OnGuard (Hilco) at 800.955.6544
Wiley X, Inc. at 800.776.7842*

*If a patient that does not have the ProTec Safety Plan, is interested in a Wiley X, Inc. frame, you must contact Wiley X directly. Wiley X requires an account to be set up to sell their frames outside of the ProTec Safety Plan.

All safety orders must be sent to the following participating lab:

VSPOne Columbus
800.251.5150
2605 Rohr Road, Lockebourne, OH 43137

Paper claim practices: You must order lab-supplied materials from the participating lab listed above.

Emergency

In emergencies, you can use any lab capable of producing ANSI certified safety eyewear (see the National Contract Lab List); choose lab 100 when billing on eClaim.

Use one of the following comments when indicating emergency status:

• Patient’s safety glasses are lost, stolen, or broken and he or she doesn’t own a back-up pair.
• Patient needs safety glasses to work or drive and is unable to see well enough to do so and doesn’t have a back-up pair of safety glasses.
• Patient’s safety and well-being will be jeopardized without the immediate delivery of his or her prescription safety eyewear.

Supplemental Safety EyeCare Exams

The level of eye exam or the evaluation and management service that you provide depends on the location and the time elapsed since the patient’s last routine eye exam:

When possible, perform your supplemental and comprehensive or intermediate exams in the same visit.

*If you choose to use 920XX codes to bill your WellVision Exams, please remember to bill refraction (92015) separately for accurate reimbursement.

Stand-Alone Safety EyeCare Plan Exams

Exams for Stand-Alone Safety EyeCare Plans are reimbursed at your Signature Plan comprehensive or intermediate exam payable fee.

Dispensing Fees

Supplemental Safety EyeCare Plans have a lens dispensing fee only. The lens dispensing is reimbursed at a flat rate of $25.

Stand-alone Safety Eyecare Plans have a lens and frame-dispensing fee that is also reimbursed at a flat rate. Both lens and frame dispensing are reimbursed at $25 each.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

LightCare™ Enhancement

Eligible members can use the LightCare enhancement for plano (non-prescription), ready-made sunglasses or blue light filtering glasses instead of contact lenses or prescription glasses, exhausting both their lens and frame eligibility.

Eligible members will be indicated with the following comment on the Patient Record Report:

Note: 

Members may receive plano (non-prescription) ready-made sunglasses or plano blue light filtering glasses instead of prescription glasses. This will exhaust both lens and frame benefits.

Frames

Coverage includes any ready-made, doctor-supplied plano sunglasses or plano blue light filtering glasses. Apply the patient's retail frame allowance to the cost of the complete pair (lens and frame). Deduct 20% from any amount over their retail allowance. Sunglasses can be ordered if not available at the time of the member’s visit. If you do not supply an inventory of ready-made blue light glasses, you can refer patient to Eyeconic. The $20 and $40 Marchon/Altair frame promotions apply to LightCare.

Lenses

To cover the lenses, the patient must select the lenses included in the frame with no additional enhancements or coatings.

When submitting claims for non-prescription sunglasses or blue light filtering glasses on eClaim, indicate the order as a “frame only” order.

A diagnosis code is required for claim submission. For frame-only claim submission, use Z46.0 (Encounter for fitting and adjustment of spectacles and contact lenses) or other relevant diagnosis code(s), as appropriate. Including a diagnosis code will ensure correct claims processing.

For all eligible LightCare Plan Enhancement claims, you’ll be reimbursed both your frame dispensing fee and a frame material fee (up to the patient’s wholesale/retail frame allowance).

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Computer VisionCare^SM Plan

Computer VisionCare services are usually provided at the same time as your patient’s routine eye exam to treat Computer Vision Syndrome (CVS). There are two Computer VisionCare plans: Supplemental Computer VisionCare and Computer VisionCare Only.

Coordination of Benefits

There’s no coordination of benefits for services provided under the Computer VisionCare Plan.

Computer VisionCare patients should complete a questionnaire about their work environments and viewing distance from the computer before the exam. A sample Computer VisionCare Questionnaire can be found in the Patient Education section in the Forms Library area under Administration on VSPOnline on eyefinity.com. Keep a copy of the questionnaire or the information in your patient’s record.

Supplemental Computer VisionCare patients are eligible for a supplemental exam to determine computer vision requirements in addition to the tests listed below.

Computer VisionCare Only: Patients receive a comprehensive exam and the tests listed below.

Additional Tests and Records

In addition to services provided under the VSP Signature Plan^®, include the following tests and records with the Computer VisionCare eye exam:

• history, including viewing distances, lighting, viewing angles, and symptoms
• vision assessment (at least two of the following):
• Function (at least two of the following):
• determination at computer viewing distance eye discussion, when indicated (only during initial visit; no coverage for ongoing treatment)
• testing as indicated, to support the diagnosis
• Near point of convergence test
• Cover test or heterophoria test at the near working distance of the computer monitor
• Fusion quality (assessment of fusion ranges when indicated)
• Facility of accommodation
• Amplitude of accommodation
• Plus and minus lenses to blur at the computer monitor working distance

Treatment requirements

• if computer glasses are indicated
• prescription, if indicated
• regarding the visual environment and workstation
• eye discussion, when indicated
• therapy, when indicated

Patients qualify for Computer VisionCare materials only if they have one of the following diagnoses. Claims require at least one of the following diagnosis codes.

Lenses

Under both plans, patients are eligible for covered lenses and a wholesale/retail frame allowance. Value-Added benefits don’t apply. Materials prescribed are for computer use only.

Spectacle lens coverage includes:

• prescription of ±0.50 diopters or greater required for lenses.
• vision, bifocal, and trifocal specifically designed for working at a computer glass/plastic.
• Variable Focus lenses (VSP lens enhancement code IA) are covered

Note: 

Although rare, some clients may choose to cover all progressives. Check the patient record report for coverage details.

• sizes up to and including 60 mm.
• prescription for supplemental Computer VisionCare materials must differ by ±0.50 diopters or greater at any distance from the patient’s everyday eyewear.

Note: 

Recognizing the advances in lens technologies, digital lenses with a built in “bump” lens attribute (minimum +0.50 diopter ADD power) offered for computer use but not for a patient’s everyday use, may be used to satisfy the ±0.50 diopters prescription difference.

• I, II or Rose tints, up to 20% absorption level.

Frame

Most VSP plans provide a blended wholesale/retail allowance toward the purchase of a new frame. Patients may also use a serviceable existing frame. If the member chooses a frame with a cost that exceeds both the wholesale and retail allowances, deduct 20% from the retail overage

Other Lens Enhancements

If your patient selects a lens enhancement that is covered with copay, charge your patient according to the VSP Signature Plan Lens Enhancements Chart or your U&C, whichever is lower. Examples of lens enhancements patients can choose:

Non-covered Materials

The following items aren’t benefits under the Computer VisionCare Plan. Clients may make exceptions to this list. Please check the Patient Record Report for coverage. If these items are provided, the lenses and frame will be denied.

• VSP contract labs.
• orders through eClaim at eyefinity.com.
• redos, please check the First-Time Doctor Redos policy in Dispensing and Patient Lens Enhancements section.
• can use non-contract labs in emergency situations only.
• in-office lens enhancements are acceptable if they follow Computer VisionCare guidelines for tints. See Doctor In-Office Lens Enhancements for details.

Claims submitted under the Computer VisionCare Plan must meet the following criteria:

• materials prescribed are for computer use only.
• include at least one of the diagnoses listed above
• prescription for Computer VisionCare materials must differ by more than ±0.50 diopters from your patient’s everyday eyewear
• patient can’t get Computer VisionCare glasses that are the same as everyday eyewear.

VSP will verify that Computer VisionCare glasses meet all requirements. Paid materials claims that don’t meet the above criteria may be reversed. You may not bill your patients for claims that are reversed.

If your patient can’t adjust to occupational progressive lens, benefits won’t be reinstated. Payment becomes a private transaction between you and your patient.

Claim Reimbursement

Supplemental Computer VisionCare: When your patient has Supplemental Computer VisionCare coverage, use their routine benefit for the eye exam and the Computer VisionCare coverage for supplemental Computer Vision Syndrome testing.

Please refer to the chart below to determine your reimbursement:

When possible, perform your supplemental and comprehensive or intermediate exams in the same visit.

*If you choose to use 920XX codes to bill your WellVision Exams, please remember to bill refraction (92015) separately for accurate reimbursement.

Computer VisionCare Only: We’ll reimburse you for exams at your VSP Signature Plan comprehensive or intermediate exam payable fee.

Computer VisionCare-related vision therapy provides evaluations and orthoptic and/or pleoptic sessions for patients with one of the following conditions:

• insufficiency— H51.11
• insufficiency— H52.521, H52.522, H52.523
• spasm— H52.531, H52.532, H52.533

Computer VisionCare-related vision therapy provides evaluations and orthoptic and/or pleoptic sessions for patients with one of the following conditions:

• insufficiency—378.83
• insufficiency—367.50
• spasm—367.53

If your patient meets the benefit criteria above and is eligible for Computer VisionCare-related vision therapy, please refer to the Vision Therapy section of this manual for billing instructions.

Coverage:

• will pay up to a maximum of $200.
• $200 allowance includes any supplemental testing. VSP does not provide coverage for supplemental testing without treatment.
• patient is responsible for additional therapy above the $200 allowance.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

VSP EasyOptions

VSP EasyOptions is an enhancement to the VSP Signature, Choice, Enhanced Advantage and Advantage plans that enables doctors and patients to customize VSP materials coverage to meet the patient’s lifestyle and visual needs.

Obtain eligibility on eyefinity.com or by calling VSP at 800.615.1883.

When retrieving an authorization, an alert box will appear on eyefinity.com and the VSP Patient Record Report will show VSP EasyOptions under Plan Details.

The VSP EasyOptions enhancement does not affect exam coverage. Refer to the VSP Patient Record Report for exam coverage information.

Potential materials coverage upgrades with VSP EasyOptions vary by client, and are shown on the VSP Patient Record Report. Patients are eligible to pick one (1) upgrade from the selection. Example upgrades include but are not limited to:

• Fully covered progressive lenses, or
• Fully covered photochromic lenses, or
• Fully covered anti-reflective coating, or
• Increased frame allowance, or
• Increased contact lens allowance

Assist the patient with frame and lens selection as normal, and then determine which upgrade provides the best value for the patient. Charge the patient for the other choices/upgrades as normal for their plan.

Note: 

If the client already covers Standard Progressive under the base plan, then only Premium and Custom Progressives are available under EasyOptions.

You’ll be reimbursed for exam and materials according to the patient’s Signature or Choice Plan coverage as normal. The best value for the patient will be calculated upon claim submission, and this selection will show on your VSP Explanation of Payment as “EasyOptions—[name] Upgrade.” Other upgrades will show as “EasyOptions—No Upgrade.”

Some clients may also have an additional $50 frame allowance upgrade for Marchon/Altair frames. You will see this upgrade on the VSP Patient Record Report under Plan Details.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Repair/Replace Benefits

Repair/Replace Benefits cover materials your patients get when they’re not eligible for materials under their core plan. Refer to the Patient Record Report to determine if the patient is eligible for repair or replacement coverage. Patients are eligible if their spectacle lenses or frames are broken or damaged and need repair or replacement.

It also covers materials your patients receive when they’re not eligible for materials under the core plan and they can no longer use their glasses.

Patients covered under this additional benefit may be entitled to eyeglass lens and frame repair. Frame repair includes temples only, front only, hinge, and miscellaneous repairs. The Repair Benefit may also include replacement of a complete frame and/or basic lens.

• Patients need to bring the glasses to you before obtaining an authorization.
• You’ll determine if glasses can be repaired. If they can’t, replacement may be covered.

Inform your patients that they must pay for services and/or materials provided if they:

• Aren’t eligible for the services/materials requested;
• Have Repair/Replace benefits but don’t meet the criteria for repair or replacement services/materials.

Contact VSP at 800.615.1883 to obtain an authorization for repair/replace benefits.

VSP Elements Program^®

VSP Elements is a covered-in-full program that supports the pediatric vision essential health benefit under the Affordable Care Act (ACA). Featuring Otis & Piper™ Eyewear, VSP Elements offers a covered-in-full annual eye exam and quality eyewear from a collection of frames designed specifically for children.

VSP Elements can be offered to patients with a Signature, Choice, or Advantage Plan. Only participating Choice Network doctors can provide services to VSP Elements patients with the Choice Plan. Only participating Advantage Network doctors can provide services to VSP Elements patients with the Advantage Plan.

Refer to the Patient Record Report to determine which Plan type the patient has. For Cigna Vision Patients, refer to the Cigna Quick Reference Chart on VSPOnline at eyefinity.com.

Copays

Copay information is provided on the Patient Record Report when you obtain an authorization.

Exam Coverage

Covered comprehensive eye exams are generally available to patients once every 12 months on a calendar year basis. Other exam frequencies can also be accommodated. Refer to the Patient Record Report for specific coverage details.

Materials Coverage

VSP Elements coverage is for children typically age 0 to 19 and includes covered prescription lenses and a frame. Covered-in-full frames are available from the Otis & Piper Eyewear Collection. Patients can select a non-Otis & Piper frame, but it will not be covered (see Out-of-Kit Frames below). Contact lenses in lieu of eyeglasses are also covered with a minimum three-month’s supply for varying modalities (see Contact Lenses below). Please review your patient’s coverage before providing materials.

Patients are also eligible for savings on additional services and materials (see Value-Added Benefits below).

Lenses

Single vision, bifocal, trifocal, or lenticular lenses in polycarbonate, plastic or glass are covered, as well as UV protection and scratch-resistant coatings. You receive a combined $25 lens and frame dispensing fee for covered lenses.

All orders for VSP Elements patients must be fulfilled at VSPOne™ Columbus.

Note: 

VSP only covers lenses that meet the minimum prescription criteria.

VSP’s minimum prescription criteria:
The combined power in any meridian is ±0.50 diopters or greater in at least one eye or one of the following exceptions occurs:
—Necessary prism of 0.50 diopters or greater in at least one eye
—Anisometropia is 0.50 diopters or greater in at least one eye
—Cylinder power is ±0.50 diopters or greater in at least one eye

Lens Enhancements

In addition to polycarbonate, UV protection and scratch-resistant coatings, some clients may also cover the following tints. Refer to the Patient Record Report for specific coverage details.

• Photochromic lenses
• Solid and gradient tints

If the patient chooses a lens enhancement not covered by the plan, charge the patient according to the appropriate Lens Enhancements Charts (Signature, Choice, or Advantage) depending on the network selected as indicated on the Patient Record Report.

Covered Frames

Frames from the Otis & Piper Eyewear Collection are covered for patients and will be lab supplied through VSPOne Columbus. You will receive a combined $25 lens and frame dispensing fee.

To request an Otis & Piper frame kit, contact Altair^® at 800.505.5557.

Frame Warranty:

An unlimited warranty is included with the frame.

Out-of-Kit Frames

Elective Frame

A patient has the option of providing their own frame or purchasing a non-Otis & Piper frame from you at 80% of U&C. If the patient purchases a non-Otis & Piper frame, it would be a private transaction and the frame will not be covered by VSP. You’ll still receive a combined $25 dispensing fee for the lens and frame, regardless of the frame brand selected. The benefit for lenses and a frame will be exhausted for the patient’s eligibility period. An out-of-kit frame selected due to cosmetic reasons, such as style, color and/or design are not covered and a private transaction at 80% of U&C.

Lenses, as outlined in the lens section, will still be covered under VSP Elements.

Medically Necessary Frame:

Out-of-kit frames are allowed and covered if medically necessary due to frame material allergies and/or the appropriate eye size is unavailable within the kit selection. For Signature and Choice plans, you receive your dispensing for lenses and frame, plus the wholesale cost. Advantage frames are reimbursed up to 55% of your billed amount.

Use a KX modifier to indicate medical necessity and be sure to complete the frame section and provide your wholesale frame cost. Document the reason for medical necessity in the patient’s chart for audit purposes.

Contact Lenses

Elective Contact Lenses

VSP Elements provides coverage for contact lens services and materials in lieu of prescription glasses with a minimum three-month’s supply (limited to two boxes of lenses) for the following modalities:

• Standard (one pair annually) – 1 contact lens per eye (total 2 lenses)
• Monthly (six-month supply) – 6 lenses per eye (total 12 lenses/2 boxes)
• Bi-weekly (three-month supply) – 6 lenses per eye (total 12 lenses/2 boxes)
• Dailies (three-month supply) – 90 lenses per eye (total 180 lenses/2 boxes)

To qualify, patients must first be eligible for contact lenses and meet the minimum prescription requirement. Refer to the Patient Record Report for the patient's specific type of coverage. The contact lens exam (fitting and evaluation) is covered in full. Providers will be reimbursed 85% of their U&C fees for the contact lens exam, and 100% for materials up to the quantity allowed.

Standard contact lens coverage exclusions apply, including corneal refractive therapy, orthokeratology, contact lenses for myopia management, plano, and replacement of lost or damaged lenses.

When submitting a paper claim, please indicate the contact lens modality and number of boxes in Box 19 on the CMS-1500 claim form.

*Washington State Requirement

Washington state regulation (WAC 284-43-5782) requires pediatric vision services to cover a calendar year’s equivalent of contact lenses for any modality dispensed. To maximize your patient’s benefit, dispensing an annual supply of contact lenses at one time is required. Refer to the Contact Lens Benefits section in the VSP Manual for more information on Covered Contact Lenses.

Note: 

Contact lens exam services are also known as the contact lens fitting and evaluation, or F&E. These services are separate from the WellVision Exam and should be dispensed only to patients who wear or want to wear contact lenses and specifically request a contact lens exam.

Visually Necessary Contact Lenses

We’ll cover contacts in full for patients meeting the established necessary contact lens benefit criteria if those patients are eligible for materials on the date of service. Refer to the Visually Necessary Contact Lenses section in the VSP Manual for more information.

Don’t balance bill your patient. Apply material (spectacle lenses and frame) copays for necessary contact lenses, unless otherwise specified.

Visually necessary contact lenses aren’t typically covered for patients who’ve received any elective cosmetic surgery, such as LASIK, PRK, or RK.

Note: 

For Visually Necessary Contact Lenses and Covered Contact Lenses, VSP will only cover an annual supply of materials based on the manufacturer’s replacement schedule.

Use of private labs or In-Office Finishing equipment is not permitted for VSP Elements patients. All orders must be submitted to VSPOne Columbus, regardless of frame brand selected.

Some VSP Elements clients provide this coverage. Low vision evaluations and aids are covered for eligible enrollees. Pre-service verification is required. Submit a Low Vision Verification Form.

A low vision evaluation is covered for members who present with moderate, severe, or profound visual impairment. A low vision evaluation includes, but is not limited to, a detailed case history, effectiveness of any low vision aids in use, visual acuity in each eye with best spectacle correction, steadiness of fixation, assessment of aids required for distance vision and near vision, evaluation of any supplemental aids, evaluation of therapeutic filters, development of treatment, counseling of patient, and advice to patient’s family (if appropriate).

Note: 

The diagnosis code describes the level of visual impairment in each eye. The AMA defines the level of visual impairment using best corrected visual acuity (BCVA) and/or visual field limitation. For example, severe visual impairment ranges are BCVA from 20/200 to 20/400, or visual field of 20 degrees or less, whichever is worse. Profound visual impairment ranges are BCVA 20/500 to 20/1000, or visual field of 10 degrees or less. VSP follows these guidelines for low vision coverage.

Low Vision Evaluation and Aids Coverage

We’ll cover an annual low vision evaluation and aids if your patient’s best corrected visual acuity is 20/70 or worse in at least one eye, or if there is a visual field of 20 degrees or less, or a hemianopsia. The request and claim should contain the correct low vision diagnosis code(s).

Don’t use the low vision coverage to provide conventional glasses or additional contact lenses. Lenses must be either specialty low vision lenses, or glasses specifically designed for use in conjunction with low vision aids. VSP’s minimum prescription requirements apply. Please include a manufacturer’s invoice when submitting a Low Vision Verification Form.

Eligibility & Authorization

If your patient meets the benefit criteria above and is eligible for low vision services, obtain a case number. To get one, complete a Low Vision Verification Form. A copy of the invoice or catalog page is needed for each low vision aid requested. Fax the form to 916.851.4733. Or mail this form to: VSP, PO Box 997100, Sacramento, CA 95899.

Low Vision Exam Coverage

Coverage includes an annual low vision evaluation. There’s no copay.

Low Vision Materials Coverage

Coverage includes all appropriate low vision aids, including prescription services and optical/non-optical aids.

Submitting Claims/Billing & Reimbursement

Submit low vision claims using our electronic claims submission system. You’ll need an authorization number, which can be found on the Benefit Authorization notice. Indicate the case number in Box 23 located on the Diagnosis and Services screen.

For proper payment, bill all covered services with the appropriate CPT or HCPCS codes from this list.

Important!

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Note: 

Low vision claims must be submitted on a separate claim from routine vision. CPT and HCPCS codes are not selectable from the drop-down box and must be manually entered.

The following are considered a private transaction between you and your patient. Your patient is fully responsible for the payment.

Exam Services

Deduct 20% on additional eye exams, including if only a refraction is performed.

Materials

Charge 80% of U&C for additional materials when complete pairs of prescription glasses and non-prescription sunglasses or blue light filtering glasses, are dispensed within 12 months of the exam. The benefit:

•  is based on your total U&C fee.
• is unlimited for 12 months on or following the date of the last covered eye exam.
• is available through any VSP doctor. Use professional judgment when evaluating prescriptions from another provider. You may request an additional exam at a 80% of your U&C fee.
• applies to prescription and non-prescription lenses.
• doesn’t apply to cleaning products or repairs of prescription lenses or frames.

Contact Lens Service Benefit

Charge 85% of U&C on all elective, and replacement contact lens services. The benefit:

• is subtracted from your U&C fee for evaluation/fitting services;
• is unlimited for 12 months on or following the date of the covered eye exam;
• is available only through a VSP Network Doctor. Use professional judgment when evaluating prescriptions from another provider. You may request an additional exam at 80% of your U&C fee;
• does not apply to materials, solutions, cleanings, and service agreements.

VSP Laser VisionCare^SM Program

• Members receive a complimentary screening as well as preoperative and postoperative services through participating VSP doctors.
• The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using microkeratome, Custom PRK or Bladeless LASIK.
• If the laser center is offering a temporary price reduction, VSP members will receive 5% off the advertised price if it is less than the usual discount price.
• Please see the Laser VisionCare program page on VSPOnline for information on how to participate or for a list of participating facilities.

Charge sales tax to your patients, as you normally would, based on your state’s sales tax laws and regulations. Refer to Sales Tax under Dispensing and Patient Options on VSPOnline for more information.

Coordination of Benefits is not allowed when VSP Elements is the secondary benefit.

For some VSP Elements patients, authorizations will expire on the last day of the month in which they are issued. You’ll receive an “Invalid Authorization” error message in eClaim if you submit a claim for a date of service not within the effective dates. If this happens, obtain a new authorization valid for the date of service and resubmit.

VSP Elements claims for exam, lenses and frames may be submitted through a Practice Management Software System. Claims for contact lens materials may NOT be submitted through a Practice Management Software system, at this time, even if integrated with Eyefinity because they will not process for correct payment. To ensure proper payment, submit contact lens claims directly through eClaim on Eyefinity or on paper. Contact Eyefinity for questions at 800.942.5353.

Orders should be returned to VSPOne Columbus. Contact the lab at 800.251.5150 for additional information.

If you need to return a defective Otis & Piper frame, contact the lab for return instructions. If a patient wants to change a frame, the lab will do a one-time redo at no charge.

Redos due to lab error

Within 60 days, redos will be expedited and redone at no cost. Call VSPOne Columbus at 800.251.5150 with any questions.

Redos due to doctor or staff error

You’ll be charged $10 for redos due to doctor or staff error within 60 days. Do not charge the patient for the redo. Call VSPOne Columbus for complete details.

Redos due to prescription changes

Lens redos due to prescription changes within 60 days are a private transaction between your practice, the patient, and the lab. VSPOne Columbus will complete a redo for $10 or you may use another lab of your choice on a private basis.

Do not send the order back to the lab. Lab will redo lenses and send them to you so you can replace old lenses.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Retinal Screening

What is Retinal Screening?

Retinal screening are retinal fundus image(s) acquired by a retinal imaging device, that are used as baseline documentation of a healthy eye or to screen for potential disease(s). These images are reviewed by a Doctor of Optometry for the detection of diseases that manifest in the posterior segment of the eye.

• Retinal screening is a separate service from a patient’s WellVision Exam^®.
• Retinal screening is not required by medical necessity.
• Retinal screening can be incorporated as part of a patient’s overall wellness care to check for disease(s) that may otherwise go undetected.
• Patients should be informed prior to services performed of any out-of-pocket cost.
• Patients have the right to decline retinal screening services.
• Retinal screening only pertains to routine, retinal fundus imaging. Scanning laser procedure such as optical coherence tomography (OCT), Heidelberg Retinal Tomography (HRT), and GDx are excluded.

Please use your best clinical judgment to determine if this service is appropriate for your patient.

Important!

Retinal screening does not replace pupil dilation.

VSP offers different coverage options related to retinal screening. The table below provides a summary of the services.

Retinal screening and fundus photography are two separate services that share the same CPT code, 92250.

•  Bill CPT code 92250 with modifier 52 to report retinal screening. Modifier 52 signifies that the service is reduced. This provides a means of reporting a reduced service without disturbing the identification of the basic service.
• Bill CPT code 92250 (without modifier 52) to report fundus photography with interpretation and report.

For a summary of how to bill retinal screening to VSP please download this one-page billing guide.

Routine retinal screening is offered as standard coverage on VSP Signature Plan^®, VSP Choice Plan^® , VSP Advantage and Enhanced Advantage Plan^® as a value-added feature to complement the WellVision Exam^® benefit.

Eligibility

Retinal screening is an enhancement to a patient’s WellVision Exam; therefore, patients are typically eligible every 12 months. However, there are no restrictions to the number of procedures performed each year.

Charging the Patient

Charge the patient $39 or your U&C fee (whichever is lower) for each routine retinal screening.

Submitting Claims and Reimbursement

For the value-added feature, you do not need to submit a claim. This charge is considered a private transaction between you and the patient. Be sure to check for retinal screening coverage before your patient pays out-of-pocket. Bill the WellVision Exam and any materials as you normally would.

Covered in full or with a set copay, routine retinal screening is offered to VSP clients for purchase as an optional benefit enhancement to the WellVision Exam under VSP Signature Plan^®, VSP Choice Plan^®, VSP Advantage Plan^®, and Enhanced Advantage Plans.

Eligibility

Please refer to the Patient Record Report for eligibility. Retinal screening is an enhancement to a WellVision Exam; therefore, patients are typically eligible every 12 months.

Charging the Patient

Please refer to the Patient Record Report for coverage amount and/or applicable copays.

Submitting Claims

Covered routine retinal screening must be billed with a patient’s WellVision Exam.

When submitting claims for routine retinal screening, use CPT code 92250 with modifier 52.

Reimbursement

For eligible routine retinal screening covered benefit claims, you’ll be reimbursed up to $39 or your U&C fees (whichever is lower) less any applicable patient copay.

If retinal screening reveals disease(s) or abnormalities, the image(s) can be billed as fundus photography with interpretation and report with appropriate documentation requirements.

Eligibility^*

Please refer to the Patient Record Report for Essential Medical Eye Care eligibility and coverage.

Charging the Patient

When a patient has Essential Medical Eye Care and a valid medical diagnosis, there is no copay and the fundus photography service is covered-in full.

Submitting Claims

Fundus photography with interpretation and report can be billed on the same day as the WellVision Exam for eligible patients. This service is covered under VSP’s supplemental medical eye care plans and must be billed with Essential Medical Eye Care authorization.

When submitting claims for fundus photography, use CPT code 92250 and a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed. No Modifier is required.

Detailed information about payable diagnosis codes and documentation requirements are available in the Essential Medical Eye Care Provider Reference Manual sections.

Reimbursement

For eligible claims, you’ll be reimbursed 80% of your U&C fee, up to the Essential Medical Eye Care maximum allowables.

Covered-in-full retinal screening (use CPT code 92250 and modifier 52) is available to patients who have diabetes but don’t show signs of diabetic eye disease.

For full coverage details, please refer to the Essential Medical Eye Care or Diabetic Eyecare Plus Program Manual.

In addition to the digital image(s) the medical record should contain:

• The patient’s name and date of the test,
• Interpretation and report, and
• The signature of the physician

Appropriate documentation includes interpretation of the test results and a notation of the findings and assessment. When the results do not identify pathology or abnormalities, it is sufficient to document “normal fundus” (Z13.5 – Encounter for screening for eye and ear disorders).

Note:

Interpretation and report is required for all retinal screening images.

If pathology is identified, the image(s) can be billed as fundus photography with interpretation and report with appropriate documentation requirements. Documentation should include, but is not limited to, relevant medical history, physical examination, findings and/or diagnosis, and treatment plan recommendations.

Fundus photography with interpretation and report is covered under VSP’s supplemental medical eye care plans and can be billed with an Essential Medical Eye Care or Diabetic Eyecare Plus authorization.

Detailed information about payable diagnosis codes is listed in the Essential Medical Eye Care and Diabetic Eyecare Plus Program Provider Reference Manual sections.

Essential Medical Eye Care

Essential Medical Eye Care provides supplemental medical eye care coverage. The patient’s medical insurance plan should be billed as the primary payer when you are contracted with the medical insurance plan’s network. Please refer to coordination of benefits in this section for more information.

Essential Medical Eye Care covers the detection, treatment, and management of ocular and/or systemic conditions that produce ocular or visual symptoms.

Examples of conditions that may be covered under the Essential Medical Eye Care include, but aren’t limited to:

The following services are not covered under Essential Medical Eye Care:

• General anesthesia surgical procedures.
• Preoperative and postoperative surgical procedures, cataract extractions, or retinal surgery.
• Refractive surgery. Services provided for refractive diagnoses may be covered under your patient’s routine benefit.
• Prescription medication or supplies of any type.
• Eyeglasses or contact lenses.

Copays, if required, apply to medical eye exams only (92002-92014, 99202-99205, 99211-99215, 99421-99423). Copays do not apply to non-exam services (e.g., diagnostic testing including fundus photography and optical coherence tomography).

Check the VSP Patient Record Report to confirm Essential Medical Eye Care coverage. Patients choosing non-covered medical services should be informed of any out-of-pocket cost and asked to sign the Patient Responsibility Statement prior to receiving services. You can find the form under the Forms section of the Administration menu on VSPOnline on eyefinity.com.

Coding and Billing Documentation Standards
Providers are responsible for accurate documentation and claim submission of services performed. Claims should be coded appropriately according to industry standard coding guidelines including, but not limited to American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT^®), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10 CM), and National Correct Coding Initiative (NCCI).

Claim submissions are subject to review including but not limited to, terms of benefit coverage, provider contract language, scope of licensure, coding policies, clinical payment guidelines, and coding software logic. All information required to support the services and medical necessity submitted on the claim is expected to be in the patient’s medical record and be available for review. VSP audits patient medical records according to the Clinical Practice Guidelines of the American Optometric Association (AOA) and the Preferred Practice Pattern^® Guidelines of the American Academy of Ophthalmology (AAO).

Interpretation and Report

For all diagnostic tests that require an interpretation and report, the medical record must include:

• Clinical findings
• Interpretation of the findings
  • Including comparative data referenced (when available)
• Clinical management plan

Diagnosis Requirements
Diagnosis codes submitted for VSP claims must align with the assessment and plan documented in the patient record. This should be in accordance with the Clinical Practice Guidelines from the American Optometric Association (AOA) and the Preferred Practice Pattern guidelines established by the American Academy of Ophthalmology (AAO). 

VSP specifically (or only) notes services that have restricted diagnosis requirements.

Reminders:

• Essential Medical Eye Care services must be submitted on a separate authorization from routine vision claims.
• Report only those services appropriate for your licensure and your state’s current regulations.
• Code to the highest degree of specificity when indicating diagnosis.
• Standard timely filing guidelines apply.

Note: 

VSP recognizes but does not currently support Place of Service (POS) code 02 for reporting telehealth services rendered from a distant site except when submitted on paper as a secondary for coordination of benefits. Additionally, VSP recognizes but does not currently support POS code 10 for reporting telehealth services provided in patient’s home.
Modifiers GQ or 95 are used to identify telemedicine services, as appropriate. Modifiers are used for information purposes only.

For information about the Interpretation and Report requirement for medical procedures, refer to Guidelines for the Interpretation and Report of Diagnostic Procedures.

Essential Medical Eye Care Reimbursement

• Medical eye exams (CPT codes 920XX and 99202-99215) are reimbursed according to VSP Signature Plan payables, as reported on your practice’s Assigned Fee Report.
• To access the Assigned Fee Report for your practice, visit VSPOnline at eyefinity.com and click the View Fees link under Practice/Doctor Updates in the Administration area.
• Additional covered services are reimbursed at 80% of your usual and customary (U&C) fee, up to the Essential Medical Eye Care maximum allowable.
• VSP’s non-exam Essential Medical Eye Care services approximate the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule amounts.

Medicaid Essential Medical Eye Care Reimbursement

• Reimbursement for approved Medicaid procedures will be 80% of your U&C fee or your state's VSP Medicaid fee schedule, whichever is lower.

• VSP’s non-exam Essential Medical Eye Care services approximate your state’s Medicaid fee schedule amounts.

Pricing Rules for Surgical Procedures (see Surgical Services section below)

•  When two or more covered surgical procedures are performed during the same operative session, multiple surgery reductions apply.
•  100% of the allowance for the most expensive surgical procedure or 80% of the billed; whichever is less.
•  50% of the allowance for the remaining surgical procedures or 80% of the billed; whichever is less.

Only one exam or office visit is payable per date of service, including any combination of VSP plans or benefits. Reimbursements aren’t available when multiple exams or office visits are submitted for the same dates of service, including the following in any combination:

• Intermediate or comprehensive routine exam
• Ophthalmological exam for medical related eye care
• Evaluation and management office visit
• Exam or evaluation and management service performed via telemedicine

Coordination of benefits (COB) applies to the payment of medical eye care benefits when a member is covered under two or more benefit plans. If a member has medical benefits under a medical health insurance plan that you’re contracted with, that plan is primary and VSP is secondary. In the event VSP is the secondary payer, VSP may be billed for the member’s out-of-pocket expenses. Examples are copayments, deductibles, charges for noncovered services, or charges for services not covered in full by the primary carrier. Providers are responsible for verifying coverage, as well as billing the other carrier(s).

See Coordination of Benefits section for more information about how to coordinate benefits.

If your patient needs more treatment than you’re licensed for, or if your patient needs treatment for services not covered under Essential Medical Eye Care, refer the patient to their primary care physician or a specialist in their medical insurance plan’s network.

When making referrals, use the following guidelines and those listed under Patient Referrals in Levels of Service section of Eye Exams:

• Follow all referral protocols set by your patient’s health plan. Typically, an HMO requires that patient referrals be coordinated by the primary care physician (PCP). However, a PPO allows patients to receive care from any medical provider without a PCP referral.
• Provide your findings, in writing, to the doctor you’re referring the patient to.
• Forward your diagnostic findings, treatment plan, and follow-up results to your patient’s primary care physician. To help you coordinate care for patients with diabetes, we provide the optional Primary Care Physician Communication Form, available in the Forms section of the Administration menu on VSPOnline at eyefinity.com and in eClaim. This easy-to-use form is a convenient way to help manage eye health for patients with diabetes and underscores the importance of regular eye exams.

Instructions for the administration of specific-client plans are outlined in Client Details. Please check client details before providing services to covered patients.

The Essential Medical Eye Care Core Benefits List describes all services covered under the Essential Medical Eye Care plan. Covered services are subject to change at VSP's discretion. Some services are limited to certain conditions/diagnosis codes and have frequency limitations. The established frequencies should accommodate the required quality care needs of most patients. 

Exams and Office Visits

Comprehensive eye exams are covered once per 12-month period. Additional comprehensive eye exams are reimbursed at the intermediate level.

Modifier 95 or GQ is used to designate telemedicine for eligible E/M services (99202 - 99215)

E&M services (99202-99215) Comprehensive eye exams are covered once per 12-month peroid. Additional Comprehensive eye exams are reimbursed at the intermediate level. 

For additional information on billing evaluation and management services, please use the following AMA resource guides:

CPT^® Evaluation and Management (E/M) Code and Guideline Changes

CPT^® Evaluation and Management (E/M) Office Revisions Level of Medical Decision Making (MDM)

Multiple surgical procedure payment reduction rules apply to the following:

Services received from a VSP network provider when medical eye care services are required for urgent or emergency care. Urgent and/or emergency facility charges are not covered. 

Use the following codes to indicate established patient, patient initiated, online digital evaluation. Limited to one online evaluation and management code per seven-day period, per chief complaint. Cannot lead to another medical visit in the next 24 hours.

Use the following codes to report your office’s consultation services only when requested by another physician. Allowable once per patient, per seven-day period. Service is not reported if the patient was seen by the consultant physician within the past 14 days. 

VSP Diabetic Eyecare Plus Program^SM

The Diabetic Eyecare Plus Program is designed to provide supplemental medical eye care services for members with diabetes, diabetic eye disease, glaucoma, or age-related macular degeneration (AMD). Diabetic Eyecare Plus coverage is secondary to other medical eye insurance coverage that may reimburse you, if you are a participating provider with the patient’s medical plan. Please refer to Coordination of Benefits section for more information.

Covered-in-full retinal screening (use CPT code 92250 and modifier 52) is available to patients who have diabetes but don’t show signs of diabetic eye disease. There is no copay for the member and VSP will reimburse $39.00 or your U&C fees, whichever is lower. Retinal screening (photos) can be billed on the same day as the WellVision^® exam, under the Diabetic Eyecare Plus authorization. For additional information, refer to retinal screening in the detailed list of covered services below.

Members with type 1 and type 2 diabetes need an annual eye exam that includes dilation to allow for the most thorough examination of the retina and optic nerve. If diabetic eye disease (e.g., diabetic retinopathy or rubeosis) is detected during a comprehensive exam and follow-up care is needed, additional medical eye care services are available under VSP’s Diabetic Eyecare Plus Program to track and monitor diabetic eye disease progression.

Additional medical eye care services available for patients with diabetes and diabetic eye disease include:

• medical follow-up exams
• fundus photography with interpretation and report
• extended ophthalmoscopy
• scanning computerized ophthalmic diagnostic imaging (SCODI) including optical coherence tomography (OCT)
• remote imaging for detection, monitoring and management of retinal disease
• one additional exam with refraction for changes in vision due to diabetes medication(s).

Coverage is also available for VSP members with glaucoma and/or age-related macular degeneration (AMD) including:

• medical follow-up exams
• Scanning computerized ophthalmic diagnostic imaging (SCODI) including optical coherence tomography (OCT)
• visual field and acuity tests
• tonometry (used to monitor and measure intraocular pressure)
• gonioscopy (examines the drainage angle of the eye)
• pachymetry (process of measuring the thickness of the cornea)

Copays, if required, apply to exams only (92002-92014, 99202-99205, 99211-99215, 99421-99423). Copays do not apply to additional professional services (e.g., retinal screening). A patient’s copay amount should never exceed your VSP payable fee for the service provided.

Check the Patient Record Report to confirm Diabetic Eyecare Plus coverage. Patients don’t need a primary care physician’s referral before their visit. Patients can make appointments or be seen immediately. Refer ineligible patients back to their medical primary care doctors, unless you participate on their medical plan panel. Patients choosing non-covered services should be informed of any out-of-pocket cost and asked to sign the Patient Responsibility Statement prior to receiving services. You can find the form under the Forms section of the Administration menu on VSPOnline on eyefinity.com

Enter the specific procedure code and related diagnosis code(s), when completing the claim online or manually on the CMS-1500 Claim Form. For full procedure code descriptions, refer to the Current Procedural Terminology (CPT^®) maintained by the American Medical Association (AMA).

Reminders:

• Diabetic Eyecare Plus services must be submitted on a separate authorization from routine vision claims.
• Report only those services appropriate for your licensure and your state’s current regulations.
• Code to the highest degree of specificity when indicating diagnosis.
• When applicable, bill the diagnosis code with the correct eye location: left, right or bilateral.
• If evaluation and management services are performed remotely, bill the CPT code with a GQ or 95 modifier, as appropriate

Note: VSP recognizes but does not currently support Place of Service (POS) code 02 for reporting telehealth services rendered from a distant site except when submitted on paper as a secondary for coordination of benefits. Additionally, VSP recognizes but does not currently support POS code 10 for reporting telehealth services provided in patient’s home.
Modifiers GQ or 95 are used to identify telemedicine services, as appropriate. Modifiers are used for information purposes only.

• Standard timely filing guidelines apply.
• When billing eye exams or other services for patients with diabetes, remember to include code 3072F to indicate no evidence of retinopathy in the prior year, when applicable. Data collection codes, including 3072F, should be billed with a $0.00 amount.

Reimbursement for eye exams (CPT codes 920XX and 99202-99215) will meet your current VSP Signature Plan payable fees. For retinal screening (photos) you’ll be reimbursed $39.00 or your U&C fees, whichever is lower. Approved additional services are reimbursed at 80% of your U&C fee, up to the VSP Essential Medical Eye Care maximum allowable.

Note: For more information about the Interpretation and Report requirement for medical procedures, refer to Guidelines for the Interpretation and Report of Diagnostic Procedures.

Coordination of benefits (COB) applies to the payment of medical eyecare benefits when a member is covered under two or more benefit plans. If a member has medical benefits under a medical health insurance plan that you’re contracted with, that plan is primary and VSP is secondary. In the event VSP is the secondary payer, VSP may be billed for the member’s out-of-pocket expenses. Examples are copayments, deductibles, charges for noncovered services, or charges for services not covered in full by the primary carrier. Providers are responsible for verifying coverage, as well as billing the other carrier(s).

See Coordination of Benefits section for more information about how to coordinate benefits.

Comprehensive eye exams are covered once per 12-month period. Additional comprehensive eye exams are reimbursed at the intermediate level.