Covered comprehensive eye exams are generally available to your patient 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.

Advantage Exam Plus Plan eye exam fees are made according to your Advantage Network Fee Schedule.

We’ll pay exam services once per eligibility period. Don’t balance bill for exams.

Advantage Exam Plus patients are entitled to savings on glasses and contact lens services. Refer to Exam Plus and Exam Plus with Allowances in the VSP Manual for more information.

Covered comprehensive eye exams are generally available to your patient 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.

Advantage Exam Plus With Allowances Plan eye exam fees are made according to your Advantage Network Fee Schedule.

We’ll pay exam services once per eligibility period. Don’t balance bill for exams.

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 or combined materials allowance. When dispensing lenses, the lens allowance (or combined materials allowance) applies 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, however the allowance schedule applies only once.

Lenses and Frame Reimbursement

For claims with a date-of-service prior to 10/1/2024, deduct 20% from your materials U&C, then apply the patient’s allowance and charge your patient for any overage. Your total reimbursement is 80% of your U&C fees.

For claims with a date-of-service of 10/1/2024 or after, deduct the member’s allowance from your materials U&C.  Then charge the patient 80% of any overage. VSP will reimburse 60% of your patient’s allowance or 60% of your U&C, whichever is less. Do not balance bill the patient for the difference between the patient’s allowance and the VSP reimbursement amount.

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 is responsible for paying any overages over the allowances listed in their client-specific schedule of allowances or combined materials allowance.

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

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 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.