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.

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 ensure correct claims processing, enter $0.00 for both wholesale and retail amounts and choose lab supplied frame option.

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.

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.

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).

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.

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.