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Participating ProviderManualYour Provider Number isVerify Eligibility or Enter Claims At:www.MESVision.comCustomer Service or Eligibility:(800) 877-6372(714) 619-4660Please Submit Paper Claims to:P.O. Box 25209Santa Ana, CA 92799This manual is the sole and exclusive property of Medical Eye Services, Inc. and ECN II, Inc.,, jointly knownas MESVision.This manual contains the rules, regulations, and policies designed to assist you as a Participating Provider.The information contained in this manual is proprietary and confidential. It may not be reproduced in part or inwhole, without written consent and authorization. Changes and updates to the manual are posted and/oravailable through the “Provider” portal of the MESVision website. If you have any questions, please contactthe Provider Care Department at providerservices@mesvision.com or toll-free at 1 (800) 877-6372.
Participating Provider ManualTitleTable of ContentsPageOverview. 2Provider Responsibilities . 3Patient Responsibilities . 6Policy Statement . 7Department of Managed Health Care Regulatory Requirements . 8Assembly Bill 684 Requirements . 9Website Eligibility Verification Guidelines . 10Interactive Voice Response System (IVR) Eligibility Verification Guidelines. 12Website Claim Submission Guidelines . 14Claim Submission Guidelines . 15Guidelines for Approval of Non-Elective (Medically-Necessary) Contact Lenses . 16Guidelines for Approval of Subnormal/Low Vision Testing and Low Vision Aids . 16Claim Resubmission Guidelines . 17Reimbursement Procedures for Overpaid Claims . 18Claims Processing Policies and Definitions. 19Limitations . 23Exclusions . 24Schedule of Allowances .Appendix IProvider Manual Amendments .Appendix IIQuality Management Program . Appendix IIIQuality Improvement Policies and Procedures . Appendix IVEvaluation Tools . Appendix VProvider Update Form* . Appendix VIClaim Form*. Appendix VIINon-Elective (Medically Necessary) Contact Lenses Approval Request Form*. Appendix VIIIGrievance Form*. Appendix IXLow Vision Benefit Request & Review Form*. Appendix X*May be reproduced as needed.MES-CA Participating Provider Manual (08-2020)1
OverviewMedical Eye Services, Inc. (MES) was incorporated in 1976 as a Preferred Provider Organization forvision plans that provide quality eye care service. MES has been licensed as a Third Party Administratorin California since 1978, holds TPA licenses throughout the United States, and is also licensed as aspecialized Health Care Service Plan in California.MES has agreements with Health Maintenance Organizations, Preferred Provider Organizations,employer groups, and insurance carriers. Vision benefit designs include Full-Service Plans, EyewearOnly Plans, Exam-Only Plans, vision plans bundled with hearing or dental, and access to a value-addeddiscount on non-covered benefits.MES represents participating providers with a choice of all three eye care professionals. The networkOphthalmologists (MDs), Opticians, and Optometrists (ODs) accept a competitive fee-for-serviceschedule of allowances as payment-in-full for covered benefits. Historically, ninety-eight (98%) percentof claims are paid to participating providers with the majority of claims submitted through the MESwebsite. Participating providers are credentialed on an ongoing basis in accordance with the standardsestablished by the National Committee for Quality Assurance (NCQA).MES administers numerous benefit designs based on a group’s requirements or bid specifications. MESis responsible for total claims administration from eligibility verification through checkwrite includingservicing all patient and provider inquiries.Random patient surveys are performed twice each month. MES continues to achieve a satisfaction levelof Excellent or Good on over ninety-five (95%) percent of responses.MES-CA Participating Provider Manual (08-2020)2
Provider ResponsibilitiesFor the purposes of this manual, “Patient” may also mean “Enrollee” or “Insured.”1. To complete the appropriate portion(s) of the claim at no charge to the patient and submit the correctcopy of the claim form to MES. Although many patients may bring a claim on the date of service, theyare not required to do so. You may reproduce the claim included in this manual or download it fromwww.MESVision.com. Providers can directly enter and submit claims on this website.2. To collect any calendar-year deductible(s) at the time services are rendered. The calendar-yeardeductible is usually paid at the time of the examination. Some vision plans, however, have doubledeductibles (examination and eyewear). Please access www.MESVision.com for specific deductibleamounts. The benefit allowance paid by MES is reduced by the deductible that is paid by the memberto the provider at the time of service.3. To inform the patient of any charges not covered under their vision plan, and/or items that have a limitedbenefit, and to include such documentation in the patient file (Please see Exclusions and Limitationssection).4. To arrange for payment of all non-covered items prior to rendering services. This is a privatearrangement between the provider and the patient.5. To submit “usual and customary" charges for all services and/or materials.6. To attach documentation to the approval form and/or claim when billing for medically necessary contactlenses, and to the claim for contact lenses and/or frame and lenses in cases of aphakia.7. To always include the prescription on or attached to the claim, and to check the appropriate box for thetype of lenses dispensed. A prescription is required even when only the frame is being dispensed.8. To conspicuously post in the office, a notice clearly stating the legal requirements and office policyregarding the release of spectacle and contact lens prescriptions in accordance with applicable law.9. To include the name, address, and provider number where indicated on the claim. It is important thatthe address on the claim is the location where services are rendered. If required information is missing,a request will be generated by MES, and the claim will be pended until the information is received. Ifthere is a problem identifying a provider, payment may be sent directly to the patient.10. To ensure that all areas of the claim are completed before submission. This will assist in expeditingclaim processing and reimbursement. It is especially important that the Social Security Number orMember Identification Number is that of the covered person and not the dependent's.11. To submit claims for processing within six (6) months from the original date of service (date of servicemeans the calendar date on which covered services were provided). The requirements of insurancecarriers, health care service plans, and employer groups indicate that claims submitted AFTER theirdeadline, from date of service, will be denied. Please note that patients are not responsible for claimssubmitted beyond the stipulated time period and therefore cannot be billed for such covered services.12. To obtain an eligibility verification in order to verify available benefits and to establish responsibility forpayment of copayments/deductibles, non-covered services, and/or materials, if any. Eligibilityverifications may be obtained through the MES website (www.MESVision.com) in addition to the MESCall Center (1-800-877-6372). Eligibility verifications are subject to prescription change, IRS dependentrequirements, and full-time student status, and are valid only for five (5) days before and five (5) daysafter date of service within the same month. Please note that an eligibility verification for self-fundedERISA groups does not guarantee payment in the event of retroactive terminations. For such situations,providers may collect from the patient or the new vision plan.13. Payment of covered services is subject to the provisions of the patient’s vision plan.MES-CA Participating Provider Manual (08-2020)3
14. To submit requests for payment adjustments timely (within 180 days) to expedite resolution andadditional payment, if applicable. All disputes (including payment adjustment requests) must besubmitted within 365 days of payment or denial. Please refer to the “Provider Dispute Resolution” Policyand Procedures.15. To submit required information within deadlines, including claims submission deadline stated onpending letters.16. To contact MES with any questions, comments, or problems regarding payments within applicabledeadlines.17. To accept reimbursement for covered services as payment-in-full and not bill the patient for anyamounts that are reduced in accordance with benefit policy guidelines including, but not limited to, feeadjustments (provider's write-off) and assessments.18. When an eligible patient does not identify her/himself as having an MES-administered vision plan, youmay bill services and materials at the time of the visit. Once coverage is disclosed, the participatingprovider is required to refund the amount paid by the patient less any copayments/deductibles, anyassessments if applicable, and payments for non-covered services or materials. Any patientresponsibility will be shown on the Explanation of Payment. The patient must disclose coverage to theprovider within the 180-day grievance filing deadline. In the event your posted office policy states thatcoverage must be disclosed at the time of service, obtaining the patient’s written acknowledgement ofthis policy and all office policies is recommended.19. To advise MES of any change in information, including change in ownership of the practice, address,telephone number, tax information, and/or opening of additional locations.20. To advise MES of new licensed associates who have joined the practice. MES requires all licensedproviders in the same office who perform routine examinations to participate in the network.21. To enroll the licensed optical dispensary as a participating provider, if lenses and frames are dispensed.22. To have a selection of at least 50 frame styles that are covered-in-full, if lenses and frames aredispensed.23. To only bill for the actual out-of-pocket expenses incurred by the patient when there is Coordination ofBenefits with another vision plan. Copies of the benefit form and the Explanation of Payment from theprimary vision plan are required.24. To ensure that all advertising regarding provider participation is not untrue, misleading, deceptive orotherwise inconsistent with existing law.25. To advise patients who purchase disposable contact lenses that these items are covered up to theirplan’s benefit allowance. Patients should be allowed to purchase lenses up to their plan’s benefitallowance or accumulate receipts within their benefit period, and then submit a claim for reimbursement.Benefit periods may be twelve (12) months or twenty-four (24) months, depending on the plan design.26. To remind patients, when applicable, that it is their responsibility to pay the difference between thecomprehensive examination allowance and the follow-up examination allowance when they elect toreceive a comprehensive examination but are only eligible for a follow-up examination. Any charge thatexceeds the comprehensive examination allowance is a provider write-off.27. To communicate freely with patients about their treatment, regardless of benefit coverage limitations.28. To refer patients covered under HMOs back to their Primary Care Physician or Participating MedicalGroup when it is suspected that additional diagnostic procedures or treatment plans may be required.Participating provider must cooperate with ultimate treating physician and provide any documentationto assure continuity of care.29. To advise MES of any change license status or any actions brought by any professional organizationand/or state agency against your license and/or practice.MES-CA Participating Provider Manual (08-2020)4
30. To notify patients of changes in the status of your MES network participation (e.g. resignation,termination, etc.) prior to rendering services. This will allow patients to seek services from MESparticipating providers, if they wish to.31. To conduct your practice within accepted norms and standards of the community.32. To abide by the bylaws, participating provider agreement, rules, regulations, and policies andprocedures adopted by the Board of Directors.33. To obtain MES’ and carrier partners’ written consent prior to use of the name, trademark(s), servicemark(s) of Medical Eye Services, Inc. (MES), ECN II, Inc. (ECN II), MESVision, or any of its carrierpartners including Blue Shield of California.34. To notify MES promptly and not exceeding five (5) business days of any provider directory informationchanges, including whether provider is accepting or not new patients.35. To direct enrollee or potential enrollee to both the plan for additional assistance and to the Departmentof Managed Healthcare to report any inaccuracy with the MES’ participating provider directory, if aprovider who is not accepting new patients is contacted by an enrollee or potential enrollee seeking tobecome a new patient.None of the provider’s responsibilities listed above shall interfere with the provider’s ability to provideinformation or assistance to their patient.MES-CA Participating Provider Manual (08-2020)5
Patient Responsibilities1. To inform the provider of their vision coverage, preferably on or before the date of service. Althoughmany patients may bring a claim on the date of service, they are not required to do so. If the patientdoes not present the claim at the time of service, please call to verify eligibility and use a duplicate ofthe claim that is provided with this manual or downloaded from the MES website(www.MESVision.com). It is imperative that you secure an eligibility verification number in order to usethis form. When an eligible patient does not identify her/himself as having an MES-administered visionplan and pays for services and materials at the time of visit, any submitted claim will be paid directly tothe participating provider. The participating provider is required to refund the amount paid by the patientless any copayments/deductibles, plus any write-offs or applicable assessments, and payments fornon-covered services or materials.2. To complete all information in Part 1 of the claim, and to release the signed and dated form.3. To pay any copayments/deductibles for each patient at the time services are rendered.4. To pay the difference between the comprehensive examination allowance and the follow-upexamination allowance when they elect to receive a comprehensive examination but are only eligiblefor a follow-up examination.5. To arrange for payment of any services/materials listed under the Exclusions and Limitations of thevision plan (please see Exclusions and Limitations section).MES-CA Participating Provider Manual (08-2020)6
Policy StatementSubject:Provision of Contact Lens Specifications(Adopted by the Board of Directors at its meeting held October 15, 1994)BackgroundThe fitting of contact lenses and the written specifications of such contact lenses differ from thedetermination of the power and characteristics of eyeglasses. With glasses, it is usually possible to arriveat a scientifically valid determination of the optical power of the spectacles at the completion of the initialexamination. Therefore, a “prescription” for glasses can be written, for which the provider is commonlyconsidered to be responsible.However, in the case of contact lenses, the performance of the lenses on the eyes must be evaluatedbefore the fitter can determine the final specifications.EvaluationThe initial comprehensive examination cannot determine all the parameters needed for properly-fittedcontact lenses. The initial examination includes a comprehensive ophthalmic evaluation to diagnose thepresence or absence of eye disease, and a refraction to determine any optical correction that may beneeded. Based on these and other measurements, the physical and optical specifications of trial contactlenses can be approximated. The evaluation of the fit of the lenses is equally important. During the fittingprocess, trial contact lenses are applied to the patient’s corneas. In some instances, a satisfactory fit isobtained, while in others, lenses of difference sizes and curvatures must be used. Sometimes it isnecessary to utilize several trial lenses before obtaining an adequate physical fit of both eyes. An overrefraction is then performed to determine the exact optical power of the lenses. Following delivery ofthese lenses, the patient is carefully re-evaluated. In some cases, after a period of wear, these lensesmay no longer be satisfactory, and lenses with other specifications may be necessary in one or botheyes.SummaryThe fitting of contact lenses involves more than the issuance of a “prescription”. The continuousevaluation of the fitting characteristics of the lenses is equally important.MES-CA Participating Provider Manual (08-2020)7
Department of Managed Health Care Regulatory RequirementsThe following provisions are required by Title 28 of the California Code of Regulations, Section 1300.67.8for all contractors that provide services to Health Care Service Plans.1. The participating provider agrees to maintain such records and provide such information to the plan orto the Commissioner of the Department of Managed Health Care as may be necessary for complianceby the plan with the provisions of the Knox-Keene Health Care Service Plan Act of 1975, as amended.Such records will be retained for at least two years whether or not this agreement is terminated byrescission or otherwise.2. The plan shall have access at reasonable times upon demand to the books, records, and papersrelating to the health care services provided to enrollees, to the cost thereof, and to payments receivedfrom enrollees of the plan (or from others on their behalf).3. Upon termination of this agreement, the participating provider agrees to continue providing services tothe enrollees under his or her care at the then current rates until the services being rendered arecompleted, unless the plan makes reasonable and medically appropriate provision for the assumptionof such services.4. The participating provider agrees to bill the plan directly for covered services rendered to eligibleenrollees rather than seeking reimbursement from the enrollees except for applicablecopayments/deductibles.5. If the plan fails to pay for covered services or supplies, the participating provider will not collect orattempt to collect from an enrollee sums owed by the plan. The enrollee shall not be liable to theparticipating provider in the event the plan fails to pay for services or supplies covered by the enrollee'scontract with the plan.6. The participating provider shall comply with the plan’s Timely Access to Non-Emergency Health CareServices policies and procedures it has developed pursuant to Section 1367.03 of the Knox-Keene Actand Title 28, California Code of Regulations, Section 1300.67.2.2 (a)(2), that are applicable tospecialized plans.7. The participating providers shall comply with the plan’s Language Assistance Program (LAP) developedpursuant to section 1367.04 of the Knox-Keene Act and Title 28, California Code of Regulations,Section 1300.67.04 (e)(4).8. The participating providers shall comply with the plan’s provider directory standards developed pursuantto section 1367.27 of the Knox-Keene Act that are applicable to specialized plans.MES-CA Participating Provider Manual (08-2020)8
Assembly Bill 684 RequirementsCalifornia Assembly Bill 684 requires the following provisions for all optometrists, as applicable.Participating provider hereby attests that:1. Provider shall comply with all applicable professional practice laws and shall provide MES with anydocuments that MES may request regarding such compliance.2. Provider shall report to MES any investigation, action or request for information received by providerfrom the Board of Optometry, the Medical Board of California, or any other regulatory entity.3. If provider is an optometrist subject to Business and Professions Code Section 655(d), Provider agreesto amend the sublease into which provider has entered to comply with the requirements of AssemblyBill 684 (effective January 1, 2016).4. To the best of Provider’s knowledge, Provider will comply with the laws contained in Assembly Bill 684(effective January 1, 2016), to the extent that such laws apply to Provider.5. Provider will inform the MES if it is subleasing space from a health plan, optical company, and/orregistered dispensing optician, as applicable.MES-CA Participating Provider Manual (08-2020)9
Website Eligibility Verification Guidelineswww.MESVision.comThis section details the process of verifying eligibility and confirming the eligible benefits of a planparticipant/patient. If at any time you need assistance, please contact a Call Center Representativeduring normal business hours, 8:00 am – 5:00 pm PST, Monday through Friday. Please note a claim canonly be filed online with an eligibility verification number.How to Access the WebsiteLog on to www.MESVision.com.1. Select the “Log In” entry button on top of the MES home page. From the drop-down list, select the“Provider Login” button.2. Enter your User Name (Provider Number) and Password (use the same numbers as you would toaccess telephonic eligibility).Note: The system only accepts five-digit user numbers. If your provider number is less than five digits,please place zeros in front of your number. (Example: provider number “456” would be entered asprovider number 00456.)3. Once the system confirms your network participation, you are then directed to the Care ProviderHome Page.To Obtain a Verification1. Select “Verify Your Patient’s Eligibility” button on the Care Provider home page. This will take youto the Subscriber Search page.2. Search by ID Number: Enter the patient’s social security number or unique identification number;or3. Search by Subscriber Name: Enter the subscriber’s first and last names, and birth date. All threedata elements are needed to execute this search.Note: If the search is unsuccessful, a box with “Subscriber not Found” will appear at the top of theSubscriber Search Page. Please double-check the entered data and try again.4. Subscriber Search Results: Includes subscriber name, group name, group number, and birth date.You are also given the option to conduct another search should this individual not be the patient forwhom you are verifying eligibility. If the patient listed is correct, select the patient’s name to revealthe status of covered dependents.5. Subscriber and Dependents Page: Includes a list of covered dependents for a specific subscriber.Once you have located the appropriate patient, select the name and you will be routed to theSubscriber Benefits page.6. Subscriber Benefits Page: Available benefits are presented including covered services (exam,lenses, and frame), benefit copayments/deductibles, and eligibility dates.7. Select the types of services that will be performed during the visit.MES-CA Participating Provider Manual (08-2020)10
Note: Be sure to mark only those services you are able to perform during the visit; marking eyewearwhen you only perform exams will prevent another participating provider from securing an eyeweareligibility verification.8. Enter the appropriate date of services then select “Get Verification Number”.9. The eligibility verification number for your patient will be displayed. We encourage you to print thispage for your patient’s file.After you receive the eligibility verification number and print a copy of the page, you may: Return to the Care Provider Home Page to verify eligibility for another patient;Select “Enter Claims” at the top of the page to proceed to the claims submission portal; orEnd your user session by logging off.To view enhancements made to the process throughout the year, please visit our website,www.MESVision.com.MES-CA Participating Provider Manual (08-2020)11
Interactive Voice Response System (IVR) Eligibility Verification GuidelinesAfter hearing the initial greeting and menu of options, you will be able to utilize the voice recognitionfeature or continue to use your telephone’s key pad to change your access code, generate or cancel anEligibility Verification for your patient(s). You can interrupt the instructions – Quick Pace – at any time byentering your request. This will allow you to move through the process at a much quicker pace once youare familiar with the system.How to Access the IVRCall (800) 877-6372 or (714) 619-4660. You will hear the initial greeting and menu of options:1. If you are calling from a provider’s office, press “1”2. For Eligibility Verification, press “1”At any time, you can press “*” to speak to a representative during normal business hours.3. Please enter your provider number4. Please enter your access codeTo Obtain a Verification1.2.3.4.5.Please press “1”Please press “1” if using a nine (9) digit SSN; orPlease press “2” if using an identification numberPlease press “1” if services will be rendered today; orPlease press “2” if services will be rendered on a different datei. Please enter the six (6) digit date of service in the following format: mm/dd/yy6. Please press “1” if the patient is the Primary Subscriber; or7. Please press “2” if the patient is a Spouse or Domestic Partner; or8. Please press “3” if the patient is a Dependenti. If the patient is a dependent, you will then be asked to enter the dependent’s eight (8) digit dateof birth in the following format: mm/dd/yyyyThe system will list all available services for the patient, including any allowances for custom benefits.The system will say the patient’s deductible or co-payment, if applicable. If there is no deductible orco-payment the system will be silent.9. Please press “1” if you are dispensing standard lenses10. Please press “2” if you are not dispensing standard lensesi. If “No” was selected, the system will list the applicable lens options and benefit amounts11. Please press “1” to receive your verification number12. Please press “2” for other optionsGenerate Additional Verifications1.2.3.4.5.6.Please press “1” if the patient is under the same subscriberPlease press “2” if the patient is under a new subscriberPlease press “3” to cancel a verificationPlease press “4” if you would like to change to a different provider numberPlease press “5” to go back to the main menuPlease press “6” if you would like to have these options repeatedMES-CA Participating Provider Manual (08-2020)12
To Change your Access Code1. Please press “2” from the main IVR menu2. Please enter your new access code. The new access code must be between 4 to 8 digits in length3. To confirm your access code, please enter your new access code numberPlease record your new access code as it will be required for future transactions.To Cancel an Eligibility Verification1. Please press “3” from the main IVR menu2. Please press “1” if the name is correct3. Please press “3” if you would like the name spelled to further confirm the patient’s name4. Please press “2” if it is not the correct patient5. Please press “1” if the patient rescheduled the appointment6. Please press “2” if the patient cancelled the appointment7. Please press “3” if the patient never showed up for the appoint
MES. Vision.com. Customer Service or Eligibility: (800) 877-6372 (714) 619-4660. Please Submit Paper Claims to: P.O. Box 25209 . . MES-CA Participating Provider Manual (08-2020) 2 Overview Medical Eye Services, Inc. (MES) was incorporated in 1976 as a Preferred Provider Organization for
