Transcription
VSP ProviderReference Manual Check out the Manuals on VSPOnline.Effective January 1, 2020
Note: This manual remains the sole and exclusive property of VSP. Theinformation contained in this manual is confidential and proprietary, and the VSPnetwork provider is granted a limited personal and nontransferrable license for useof the content of this manual during participation on the VSP network. Thecontents of this manual may not be used, copied, and/or reproduced for anyother purpose, or disclosed and/or disseminated to any third party for anypurpose whatsoever, without the prior written consent of VSP. If, for any reason,the manual recipient no longer participates on the VSP network, the doctorhereby agrees, and is directed, to immediately destroy this manual, all copies,and any and all amendments and addenda that may be issued by VSP fromtime to time. 2020 Vision Service Plan. All rights reserved.VSP is a registered trademark of Vision Service Plan. 35084 VCDR
VSP PROVIDER REFERENCE MANUALWELCOME TO VSP . 4SCOPE OF THE MANUAL . 5CONTACTING VSP . 6GLOSSARY . 8ELIGIBILITY AND AUTHORIZATION .12DETERMINING A PATIENT'S ELIGIBILITY .12SUBMITTING CLAIMS/TIMELINESS .14CLAIM APPEALS .26COORDINATION OF BENEFITS .29DETERMINING AND APPLYING BENEFITS .29.34COB ROUTINE SECONDARY ALLOWANCES .35COB CLIENT EXCEPTION RULES .37SUBMITTING COB CLAIMS .38COB RESOURCES .41PLANS AND COVERAGES .44VSP SIGNATURE PLAN .44VSP ACCESS PLAN & VSP ACCESS INDEMNITY PLANSM .50CONTACT LENS BENEFITS .51VSP ACCESS PLAN & VSP ACCESS INDEMNITY PLANSM .63VSP INTEGRATED PRIMARY EYECARE PROGRAMSM .67VSP PRIMARY EYECARE PLANSM .68VSP DIABETIC EYECARE PLUS PROGRAMSM.98VSP EASYOPTIONS .128VSP ELEMENTS PROGRAM .129VSP EXAM PLUS PLANSM AND VSP EXAM PLUS WITH ALLOWANCES PLANSM.135LASER VISIONCARESM PROGRAM .138LOW VISION.141SAFETY EYECARE PLAN.144PROTEC SAFETY PLAN .148COMPUTER VISIONCARESM PLAN .152VISION THERAPY .157INTERIM BENEFITS .159REPAIR/REPLACE BENEFITS .159RETINAL SCREENING .161SUNCARE ENHANCEMENT .163TELEMEDICINE .164EYE EXAMS .167LEVELS OF SERVICE .167PEDIATRIC EYE EXAMS .171SUPPLEMENTAL TESTING .175EXAM DOCUMENTATION .176MEDICAL-RECORD DOCUMENTATION .180CONTACT LENS CASE MANAGEMENT PROCEDURES .183CLINICAL PRACTICE GUIDELINES (ALGORITHMS) .186.188DISPENSING & PATIENT LENS ENHANCEMENTS .196USING OUR CONTRACT LAB SYSTEM .196UPDATED 6/201
VSP PROVIDER REFERENCE MANUALUSING OUR CONTRACT LAB SYSTEM (AL, AR, FL, GA, KS, ME, MO, NJ, OH, OR, PA, TX, VA, VTAND WV ONLY).199VSP IN-OFFICE FINISHING PROGRAM .201NATIONAL CONTRACT LAB LIST .205PATIENT LENS ENHANCEMENT FEES INSTRUCTIONS .211PATIENT LENS ENHANCEMENT EXPLANATIONS .214SALES TAX .223PRODUCT INDEX .224PROPRIETARY LENS AND FRAME .454DOCTOR IN-OFFICE LENS ENHANCEMENTS .459PROVIDING FRAMES .461FRAME COMPANIES/LINES .464FIRST-TIME DOCTOR REDOS .470CLIENT DETAILS .473ANTHEM BLUE CROSS.473ATLANTA PUBLIC SCHOOLS CLIENT DETAILS .475BCBSM-MESSA (BLUE CROSS BLUE SHIELD OF MICHIGAN - MESSA) .476CENTERPOINT ENERGY .480COVENTRY HEALTH CARE OF VIRGINIA, COVENTRY HEALTH CARE OF W EST VIRGINIA , COVENTRYHEALTH AND LIFE INSURANCE COMPANY .481ELECTIVE CONTACT LENS COPAYMENT EXCEPTION CLIENTS .483ELECTIVE CONTACT LENS COVERED IN FULL EXCEPTION CLIENTS .485HEXCEL CORP CLIENTS DETAILS (UTAH EMPLOYEES ONLY) .486HOMETOWN HEALTH PLAN INTEGRATED PRIMARY EYECARE .487IDAHO POWER COMPANY CLIENT DETAILS .489L3 TECHNOLOGIES .490NAVAJO TRANSITIONAL ENERGY COMPANY .491NV ENERGY CLIENT DETAILS .492POST-CATARACT ENHANCEMENT CLIENTS .493PRINCIPAL FINANCIAL GROUP .494RAYTHEON COMPANY .494TELEPHONE AND DATA SYSTEMS INC. (TDS).497THE GREENBRIER COMPANIES INC .498THE VANGUARD GROUP CLIENT DETAILS .500TUCSON ELECTRIC POWER .501UNION BENEFITS TRUST.502UNITED PARCEL SERVICE (UPS) .502VSP GLOBAL CLIENT DETAILS .503VULCAN MATERIALS CLIENT DETAILS (ALABAMA EMPLOYEES ONLY) .505POLICIES .506BUSINESS CONTINUITY PLAN .506COMPLAINTS AND GRIEVANCES .507CREDENTIALING AND RECREDENTIALING .508INSURANCE, LICENSURE AND CERTIFICATION .511MEDICAID & MEDICARE COMPLIANCE .512OFFICE STANDARDS .516PROVIDER DISPUTE RESOLUTION PROCEDURE.520PATIENTS’ RIGHTS AND RESPONSIBILITIES .521SERVICES SUBJECT TO REVIEW /AUDIT.525QUALITY ASSURANCE PROGRAM .527QUALITY MANAGEMENT PROGRAM .528UPDATED 6/202
VSP PROVIDER REFERENCE MANUALEYE HEALTH MANAGEMENT PROGRAM .530REIMBURSEMENT .534USE OF THE VSP NAME AND LOGO .536VSP'S PRIVACY COMMITMENT .539VSP’S FRAUD, W ASTE AND ABUSE POLICY .540VSP ELECTRONIC FUNDS TRANSFER AND EXPLANATION OF PAYMENT POLICIES .545VSP SAVINGS STATEMENT .5462018 VSP SIGNATURE PLAN LENS ENHANCEMENTS CHART . .5472020 VSP SIGNATURE PLAN LENS ENHANCEMENTS CHART. . .551UPDATED 6/203
VSP PROVIDER REFERENCE MANUALWELCOME TO VSPWelcome to VSP Vision Care. We’re committed to providing access to high-quality,affordable eye care, and eyewear. Partnering with 39,000 network doctors and more than 89million members worldwide, our focus is creating value for patients and opportunities for VSPnetwork doctors. 2020 Vision Service Plan. All rights reserved.VSP and VSP Global are registered trademarks of Vision Service Plan.This material is confidential, intended for the use by VSP doctors only. The contents may notbe shared with any unauthorized person. This manual is the property of VSP.UPDATED 6/204
VSP PROVIDER REFERENCE MANUALSCOPE OF THE MANUALUse this manual in combination with your patient’s Patient Record Report. If you participate inother 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 VSPcoverage, determining which benefits apply, and submitting claims forreimbursement. Plans and Coverages: Covered services and administration of Vision Service Plan eyecare plans. Eye Exams: Standard exam and supplemental test procedures for children andadults. Also includes processes for documentation requirements and referrals. Dispensing and Patient Lens Enhancements: Procedures for dispensingspectacle lenses and frames to patients. Also explains the use of contract labs andhow to administer a necessary redo. Client Details: Specifics about benefits, coordination of benefits, andreimbursement. Policies: A listing of VSP’s policies and procedures for quality management,reimbursement, office standards, advertising, and safety.Tools for Locating InformationThe Table of Contents, lists the main manual topics by section.The Glossary, located in the back of the manual, provides an alphabetical listing of commonterms used throughout this manual. A concise definition is provided for each term.UPDATED 6/205
VSP PROVIDER REFERENCE MANUALCONTACTING VSPContacting VSP by Phone and EmailServiceProvider ServicesNumber800.615.1883NotesRepresentatives are available to answer questionsfrom:Monday - Friday 5:00 a.m. to 8:00 p.m. PSTSaturday - 7:00 a.m. to 8:00 p.m. PSTSunday - 7:00 a.m. – 8 p.m. PSTYou may also refer VSP members to vsp.com.After dialing, you’ll be greeted by our InteractiveVoice Response (IVR) system. After thesalutation, you may reach a representative byselecting from the following options:Press 1: Eligibility and authorization informationPress 2: All other inquiriesProvider r Relations will answer the followingquestions:Becoming a VSP Provider, revenue generatingopportunities and training opportunities for doctorsand staff.Credentialing/recredentialing and updatingpractice information.Member Services(Patients)800.877.7195Representatives are available to answer questionsfrom patients:Monday - Friday 5:00 a.m. to 8:00 p.m. PSTSaturday - 7:00 a.m. to 8:00 p.m. PSTSunday - 7:00 a.m. – 8 p.m. PSTYou may also refer VSP members to vsp.com.Contacting VSP by MailCorrespondenceVSPPO Box 997100Sacramento, CA 95899-7100UPDATED 6/20In-Network ClaimsVSPPO Box 385020Birmingham, AL 35238-5020Out-of-Network ClaimsVSPPO Box 358018Birmingham, AL 35238-50186
VSP PROVIDER REFERENCE MANUALOrdering Supplies and FormsSHIPPING TIMEMost shipments will be sent UPS ground. Please allow the appropriate time for shipment. Ifyou need faster delivery, please make note of the priority on your request.ORDERING ONLINEYou may order supplies through VSPOnline on eyefinity.com.ORDERING BY PHONECall the Provider Services Support Line at 800.615.1883.UPDATED 6/207
VSP PROVIDER REFERENCE MANUALGLOSSARYAcute EyeCareAdministrativeSimplificationA VSP product covering patients who need urgent care.Administrative Simplification, or Title II of the Health InsurancePortability and Accountability Act (HIPAA), will standardize specificelectronic transactions used in the healthcare industry. This requiresprotecting patient privacy and ensuring the security, integrity andauthenticity of health information.AlgorithmIn this context, a step-by-step description of the suggested procedurefor monitoring and/or treating certain conditions. Algorithms areintended to provide guidance only; they never replace a doctor’sprofessional judgment.AllowanceThe maximum amount, in dollars, we will pay toward a certain service.AuthorizationThe process of making sure a patient’s eyecare may be covered byVSP. Authorization doesn’t guarantee payment for a service.BenefitIn this context, the type and amount of coverage for a service.Birthday RuleA way to determine the primary vision plan for dependent childrencovered by more than one plan. In this case, the primary plan is theone held by the parent whose birthday comes first in the calendar year.ClaimA healthcare provider’s request to a health plan for payment and thenecessary accompanying information.CMS-1500Formerly HCFA-1500. A federally approved claim form used to recordthe patient’s condition and bill for services rendered.Coordination of Also called COB. The process of coordinating multiple plans for aBenefitssingle patient visit.Contract LabAn optical lab that has signed a contract with us to make lenses for ourpatients.CopayPayment collected from a patient before services are given. Copaysvary between plans, clients and levels of coverage.CoverageA term showing that the cost of a certain service provided to a patientwill be reimbursed by us in part or in full.CPT Code“Current Procedural Technology Code.” An identifying code anddescriptive term used to report services and procedures.CredentialingThe process of ensuring our doctors meet standards including currentlicensing and board certification, as applicable.DiabeticA VSP product that provides medical eyecare services for patients withEyecareType 1 diabetes.ProgramDispensingThe process of providing materials, such as lenses, frames and contactlenses to patients.EligibilityWhether a patient can get VSP benefits.Encounter Data Detailed patient demographic, health and health insurance informationcollected from a CMS-1500 claim form.UPDATED 6/208
VSP PROVIDER REFERENCE MANUALFee-For-Service Health coverage in which doctors and other providers receive a fee forPlan (FFS)each service such as an office visit, test, procedure or other healthcareservice. The plan will either pay the medical provider directly orreimburse the patient for covered services after the patient has paid thebill and filed an insurance claim. Patients can get medical care fromdoctors they choose.First-Time Redo The one-time remaking of a lens that falls within our first-time redopolicy.Frame Overage The dollar amount patients must pay when they choose a frame whosecost exceeds both the patient’s wholesale and retail frame allowance.Gender RuleA way to designate a primary vision plan for dependent childrencovered by more than one vision plan. In this case, the father usuallyholds the primary plan.Half-Pair Lens Typically refers to a patient lens enhancement when the doctor orenhancementpatient requests the enhancement on only one lens, rather than a pairof prescription lenses.HCPCSHCFA's Common Procedure-Coding System. A list of descriptive termsand identifying codes for reporting medical services given byhealthcare providers.HealthA type of health plan that provides care through a network of doctors inMaintenanceparticular geographic or service areas. HMOs coordinate theOrganizationhealthcare services patients receive.(HMO)HEDISHealthcare Effectiveness Data and Information Set. A set ofstandardized measures designed to assess health plan performance.HIPAAThe Health Insurance Portability and Accountability Act (HIPAA) isfederal legislation intended to improve the portability and continuity ofhealth benefits, to ensure greater accountability for healthcare fraudand to simplify administering health insurance.IndependentAn optical lab not under contract with us.LabInterim Benefit A supplemental benefit (offered by some VSP clients) that coversservices before the patient’s next eligibility date. Interim benefitsparticularly apply when there are significant changes in the patient’sprescription.IVRInteractive Voice Response. This is our automated system allowingdoctors to access patient eligibility and coverage by phone.LaserA VSP eyecare plan offering coverage for laser procedures.VisionCareLensCosmetic lens features or enhancements. Patients pay the PatientEnhancements Copay unless their plans cover that enhancement. Examples of lensenhancements include tints, polycarbonate and anti-reflective coatings.Medical Record Patient medical records are submitted to VSP and reviewed by OD/MDReviewauditors who verify the exam and treatment for each patient followsestablished criteria and is properly documented.MemberA person enrolled in a VSP plan who is the primary insured.NCQANational Committee for Quality Assurance. This is an independent, notfor-profit organization setting health plan accreditation standards.UPDATED 6/209
VSP PROVIDER REFERENCE MANUALOrder ofBenefitsOverageMedical rimaryCoveragePrimaryEyeCarePrimary PlanReferralReimbursementExplanation ofPayment (EOP)Schedule ondary PlanService forServiceServiceVerificationU&C; U&C FeesVDTUPDATED 6/20The sequence in which benefits are exhausted, beginning with primaryplans, secondary plans and then numerically succeeding plans.Amount the patient pays the doctor (in addition to the copay) forservices and products not covered by any plan.Patient medical records are submitted to VSP and reviewed by OD/MDauditors who verify the exam and treatment for each patient followsestablished criteria and is properly documented.Primary Care Physician. The doctor the patient usually visits.A fee-for-service option where a member can choose plan-selectedproviders who have agreements with the plan. When a member uses aPPO provider, they pay less money out-of-pocket for medical servicethan when they use a non-PPO provider.In coordination of benefits, the primary coverage is held by the personwhose benefits will be exhausted before benefits from secondary andother plans are used.A VSP product that provides supplemental medical eyecare servicesfor the detection, treatment and management of ocular and/or systemicconditions that produce ocular or visual symptoms.The plan held by the person whose benefits are exhausted first,following the order of benefits.The process doctors use to direct patients to consult with anotherdoctor.Money paid to doctors for covered services.A statement explaining service payments and adjustments included inVSP doctor reimbursements. Also called an Explanation of Benefits(EOB) or Remittance Advice (RA).A list of services patients are covered for, and the amounts to whichpatients are covered, according to their plans.The amount available for each benefit when VSP is the secondaryplan.In coordination of benefits, secondary coverage is held by the personwhose benefits are used after benefits from the primary plan have beenexhausted.The plan held by the person whose benefits are used after primary planbenefits have been used.The secondary allowance is applied first to the same service or productof the primary plan (exam to exam, lens to lens, frame to frame, etc.).Any benefit amounts remaining after applying the allowance to a likebenefit can be used for other services.The process for making sure a service is covered and we’ll reimburseyou for that service before you give that service. You’ll be notifiedwhich services need special processing to obtain a case number.Usual and Customary Fees. These are a doctor’s standard, unmodifiedcharges for given services.Video Display Terminal. This term is used mainly when talking aboutour VDT VisionCare plan.10
VSP PROVIDER REFERENCE MANUALVSP NetworkDoctorUPDATED 6/20An optometrist or ophthalmologist who’s signed a contract to take partin our doctor network.11
VSP PROVIDER REFERENCE MANUALELIGIBILITY AND AUTHORIZATIONDETERMINING A PATIENT'S ELIGIBILITYAuthorizing Coverage and BenefitsBefore providing services, make sure your patient is eligible for benefits by retrieving anauthorization. At that time, you’ll get information about your patient’s plan, coverage, andcurrent benefit eligibility. You’ll also get a unique authorization number for your patient.Remember: an authorization number doesn’t guarantee payment. Review any comments ornotations at the bottom of the Patient Record Report to confirm patient eligibility. Confirmationis required to show that the services and materials provided meet our plan requirementsbefore issuing payment.Obtaining an Authorization NumberThere are two ways to get it: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.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.Quick Tip: Enter more information for best results.Important! Make sure you choose the correct member and patient prior to issuing anauthorization. If you’re not sure which member to choose, call VSP at 800.615.1883for assistance.2. Customer Service: Call VSP at 800.615.1883. Select “1” to use our automatedphone system. Or, you can talk with a Customer Service representative who’ll checkthe patient’s current eligibility, provide plan information, and issue an authorizationnumber.Important! Authorizations are usually effective for 30 days from the issue date. You’llreceive an ‘Invalid Authorization’ error message in eClaim if you submit a claim for adate of service not within the effective dates. If this happens, obtain a newauthorization valid for the date of service and resubmit.When you contact us, please provide the following information: Member and patient’s nameMember and patient’s DOBDate of serviceUPDATED 6/20 Last 4 digits of the member’s SSNor the full client-assigned ID numberRelationship to insured, if needed12
VSP PROVIDER REFERENCE MANUALUnderstanding Your Patient’s CoverageRefer to the Patient Record Report or the Lens Enhancements Charges Report for anexplanation of your patient’s coverage.Important! Before ordering or providing services, tell your patients that they’reresponsible for payment of non-covered services and materials.Member Vision CardVSP 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 forbenefit coverage information. You must verify your patient’s eligibility and obtain anauthorization on eyefinity.com. To view what information is available on the card, pleaserefer to the Member Vision Card Quick Reference Guide.UPDATED 6/2013
VSP PROVIDER REFERENCE MANUALSUBMITTING CLAIMS/TIMELINESSIn 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 theorder and submits the claim to VSP.Remember to bill your U&C f
VSP PROVIDER REFERENCE MANUAL UPDATED_6/20 4 WELCOME TO VSP Welcome to VSP Vision Care. We're committed to providing access to high-quality, affordable eye care, and eyewear. Partnering with 39,000 network doctors and more than 89
