Enrollment/Doctor Participation

All VSP doctors are part of the VSP Network.

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.

Fully covered comprehensive eye exams are generally available to the patient once every 12 or 24 months, calculated on a service year, calendar year or fiscal year basis. Refer to Eye Exams for levels of service.

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).

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

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.

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 Repot 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.

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.

Retinal Screening Value Added Feature

• Patients are eligible for routine retinal screening as a value added feature to complement their WellVision Exam^® benefit.
• Please see the Retinal Screening section on the VSP Manual for more information.

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.

Diabetic Eyecare Plus Program^SM

• The Diabetic Eyecare Plus Program provides medical eye care services for members with diabetic eye disease, glaucoma, or age-related macular degeneration (AMD). Retinal screening is also available to eligible patients who have diabetes but don’t show signs of diabetic eye disease.
• Please see the Diabetic Eyecare Plus Program^SM section for more information

*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.