Advantage Network Plans

This supplement to the VSP Manual provides information about coverage available to VSP members through the Advantage Network.

Only participating Advantage Network doctors can provide services to VSP members with a plan that uses the Advantage Network.

Eligibility & Authorization

Before providing services, make sure your patient is eligible for benefits by retrieving an authorization. At that time, you’ll get information about your patient’s plan, coverage, and current benefit eligibility. You’ll also get a unique authorization number for your patient. Remember: an authorization number doesn’t guarantee payment. Review any comments or notations at the bottom of the Patient Record Report to confirm patient eligibility. Confirmation is required to show that the services and materials provided meet our plan requirements before issuing payment.

Obtain an authorization on eyefinity.com or by calling VSP at 800.615.1883.

For additional information on obtaining an authorization, refer to Eligibility and Authorization page details.

We’ll indicate copays when you obtain authorization.

Note: 

Don’t waive copays.

Refer to the Patient Record Report or the Lens Enhancements Charges Report for an explanation of your patient’s coverage.

Important! 

Before ordering or providing services, tell your patients that they're responsible for payment of non-covered services and materials.

Exam Coverage

Covered comprehensive eye exams are generally available to patients once every 12 or 24 months on a service, fiscal, or calendar year basis. Provide the level of exam necessary to determine your patient’s eye health and visual status.

Patients may also be covered for:

• Essential Medical Eye Care services. For more information, see Essential Medical Eye Care in the VSP Manual.
• Retinal Screening. For more information about the Retinal Screening Value-Added Feature and Retinal Screening Covered Benefit, see Retinal Screening in the VSP Manual.

Eye exams are reimbursed at 80% of your U&C fee, up to the maximum amount shown on the appropriate Advantage Network Fee Schedule, less any exam copay. See Eye Exams in the VSP Manual for additional information. Exam services are paid only once per eligibility period. Don’t balance bill for exams.

View your Advantage Network Fees located under Quick Links and Tools on VSPOnline, then click View Fees link. On the Fee Inquiry page, click Advantage button to view the plan’s fee schedules.

Note: 

Refractions are included in your exam fees.

Materials Coverage – VSP Advantage Plan^SM

Coverage typically includes necessary prescription lenses and a frame up to a client-specified retail allowance, or an allowance toward contact lenses. Please review the patient’s coverage before providing materials.

Patients are also eligible for benefits on additional materials (see Value Added Benefits below).

Spectacle lens coverage under the VSP Advantage Plan is designed to provide necessary lenses covered in full. Your base lens payment includes your reimbursement for the following:

• Single vision, bifocal, trifocal, or lenticular lenses in plastic or glass
• Eye size up to and including 60mm
• Polycarbonate lenses for dependent children, monocular patients, and handicapped patients
• Lined multifocal lenses in all segment widths, including occupational lenses. See the Dispensing & Lens Enhancements section of the VSP Manual for specific details on occupational lenses
• Prism and slab off
• Base curves (regardless of curve)

We only cover lenses that meet the minimum prescription criteria, unless your patient is eligible for plano lenses.
Here’s our minimum prescription criteria:
The combined power in any meridian is ±0.50 diopters or greater in at least one eye or one of the following exceptions occurs:
—Necessary prism of 0.50 diopters or greater in at least one eye
—Anisometropia is 0.50 diopters or greater in at least one eye  
—Cylinder power is ±0.50 diopters or greater in at least one eye

Other Lens Enhancements

If your patient selects a lens enhancement that is covered with copay, collect the lens enhancement copay directly from the patient. You’ll be charged back the VSP Advantage Plan Lab Allocation fee for those lens enhancements.

Covered with Additional Copay

For lens enhancements that are covered with additional copay, charge the patient the patient copay listed in the VSP Advantage Network Lens Enhancements Chart or 80% of your U&C fees, whichever is lower.

Covered with Additional Copay, 80% U&C

For lens enhancements not listed on the VSP Advantage Network Lens Enhancements Chart, charge 80% of your U&C fees.

Patient Charges

The following examples illustrate how to calculate “add-on” fees based on your total prices for a specific lens enhancement:

Covered Lens Enhancements

If your patient chooses a covered lens enhancement, you’ll receive the VSP Advantage Plan covered service fee. We won’t apply a charge back.

Flexible Lens Enhancements

To offer more customized coverage to clients and members, we’ve developed several flexible lens enhancement programs that allow partial coverage for the most popular VSP lens enhancements, including anti-reflective (AR) coatings, photochromics, and progressives. Always refer to the Patient Record Report and Lens Enhancements Charges Report for complete information on lens enhancement coverage. The VSP Flexible Lens Enhancements Coverage Tip Sheet provides more information and helps you calculate patients' out-of-pocket expenses.

Note:

We’ll only cover frames when the lenses meet the minimum prescription criteria, unless your patient is eligible for plano lenses.

VSP Advantage Plan patients receive a client-defined retail frame allowance. We’ll pay you 55% of the retail price of the frame, up to 55% of the patient’s retail frame allowance. Charge 80% of U&C on the retail frame overage.

Effective January 1, 2014, most patients with a VSP Advantage Plan will have an extra $20 on top of their frame allowance when they select Marchon^® or Altair^® frames. Look for the retail allowances for Marchon/Altair and all other frames indicated on the Patient Record Report at authorization. You’ll be reimbursed up to 55% of the patient’s retail frame allowance for the frame brand dispensed.

Bill all frames as “doctor supplied” since we’re paying you directly. Your practice is responsible for paying the lab for any lab-supplied frames.

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. Check the Patient Record Report for the patient’s specific type of coverage and contact lens allowances. Refer to Contact Lens Benefits in the VSP Manual for more information.

Covered Contact Lenses: Your patient is covered for a contact lens exam and an annual supply of contact lenses.

The benefits below are considered a private transaction between you and your patient. The patient is fully responsible for the payment of any additional items.

Glasses

Charge 80% of U&C for additional materials when complete pairs of prescription and non-prescription glasses, sunglasses, and 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 U&C;
• applies to prescription and non-prescription lenses;
• doesn’t apply to cleaning products or repairs of prescription lenses or frames.

Note:

If a patient has coverage for lenses every 12 months and a frame every 24 months, charge 80% of U&C for the frame in the year when the patient is eligible for lenses but not for frame.

Contact Lenses

Charge 85% of U&C on contact lens exam services (fitting and evaluation). This benefit:

• is subtracted from your U&C fee for evaluation, fitting, and follow-up services for prescription contact lenses;
• is unlimited for 12 months on or following the date of the 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 80% of U&C;
• doesn’t apply to lenses, solution, 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 of the VSP Manual for more information. 

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 the microkeratome only 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 visit VSPOnline and reference the Laser VisionCare Program^SM page under Plans & Coverages for information on how to participate and a list of participating facilities.

The VSP Advantage Plan may also be sold with the following supplemental plans:

Advantage Computer VisionCare^SM Plan

Note: If your patient chooses a covered lens enhancement, there’s no charge. If your patient selects any other lens enhancements charge the patient according to the VSP Advantage Plan Lens Enhancements Chart or your U&C fees, whichever is lower. You may charge 80% of your U&C fees for lens enhancements not listed on the VSP Advantage Plan Lens Enhancements Chart. You’ll be charged back the VSP Advantage Plan lab fee for those lens enhancements.

See the VSP Computer VisionCare Plan section of the VSP Manual for more information.

Advantage Additional Pair

Note: If your patient chooses a covered lens enhancement, there’s no charge. If your patient selects any other lens enhancements charge the patient according to the VSP Advantage Plan Lens Enhancements Chart or your U&C fees, whichever is lower. You may charge 80% of your U&C fees for lens enhancements not listed on the VSP Advantage Plan Lens Enhancements Chart. You’ll be charged back the VSP Advantage Plan lab fee for those lens enhancements. 

Doctors are paid Advantage fees for the materials dispensing. See Lab instructions for materials dispensed under these supplemental plans.

Reminder: Obtain a separate authorization for these plans and follow the plan information provided on the authorization.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Materials Coverage – VSP Essentials Plan

Materials coverage matches the VSP Advantage Plan except for lens enhancements, as outlined below.

Covered Lens Enhancements

If your patient chooses a covered lens enhancement, you’ll receive the Advantage Network Lens Enhancements Chart covered service fee. We won’t apply the charge-back fee.

Other Lens Enhancements

If your patient selects any other lens enhancement, charge the patient 80% of your U&C fees and collect the lens enhancement cost directly from the patient. You’ll be charged back the Advantage Plan Network Lab Allocation fee for those lens enhancements.

Patient Charges

The following examples illustrate how to calculate “add-on” fees based on your total prices for a specific lens enhancement:

Flexible Lens Enhancements

To offer more customized coverage to clients and members, we’ve developed several flexible lens enhancement programs that allow partial coverage for the most popular VSP lens enhancements, including anti-reflective (AR) coatings, photochromics, and progressives. Always refer to the online Patient Record Report and Lens Enhancements Charges Report for complete information on lens enhancement coverage. The VSP Flexible Lens Enhancement Coverage Tip Sheet provides more information and helps you calculate patients' out-of-pocket expenses.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

VSP Elements Program^®

For more information on VSP Elements, refer to the Plans and Coverages section in the VSP Manual.

Materials Coverage - VSP Enhanced Advantage Plan^SM

The VSP Enhanced Advantage Plan is a new full-service plan that offers choice, flexibility, and value through a VSP Advantage Network Provider.

Coverage typically includes necessary prescription lenses and a frame up to a client-specified allowance, or an allowance toward contact lenses. Please review the patient’s coverage before providing materials.

Patients are also eligible for benefits on additional materials (see Value Added Benefits below).

Lenses

Spectacle lens coverage under the VSP Enhanced Advantage Plan is designed to provide necessary lenses covered in full. Your base lens payment includes your reimbursement for the following:

• Single vision, bifocal, trifocal, or lenticular lenses in plastic or glass
•  Eye sizes up to and including 60mm
•  Polycarbonate lenses for monocular patients, dependent children, and handicapped patients
•  Lined multifocal lenses in all segment widths, including occupational lenses. See the Dispensing & Patient Lens Enhancements section of the VSP Manual for specific details on occupational lenses
•  Prism and slab off
•  Base curves (regardless of curve)

We only cover lenses that meet the minimum prescription criteria, unless your patient is eligible for plano lenses.
Here’s our minimum prescription criteria:
The combined power in any meridian is ±0.50 diopters or greater in at least one eye or one of the following exceptions occurs:
—Necessary prism of 0.50 diopters or greater in at least one eye.
—Anisometropia is 0.50 diopters or greater in at least one eye.
—Cylinder power is ±0.50 diopters or greater in at least one eye.

Covered Lens Enhancements

If a patient chooses a covered lens enhancement, you’ll receive the VSP Enhanced Advantage Plan covered service fee. We won’t apply a charge back.

Note:

Covered service fees don’t apply to polycarbonate lenses dispensed to children or handicapped patients.

Other Lens Enhancements

Covered with Additional Copay: For lens enhancements that are covered with copay, charge the patient the patient copay listed on the VSP Enhanced Advantage Plan Lens Enhancement Chart or 80% of your U&C fees, whichever is lower, or the client-specific copay indicated on the Patient Lens Enhancement Report.

Flexible Lens Enhancements

To offer more customized coverage to clients and members, we’ve developed flexible lens enhancement programs that allow a client-specific copay or allowance for partial coverage for the most popular VSP lens enhancements, including anti-reflective (AR) coatings, photochromics, and progressives. Always refer to the online Patient Record Report and Lens Enhancements Charges report for complete information on lens enhancement coverage. The VSP Flexible Lens Enhancement Coverage Tip Sheet provides more information and helps you calculate patients' out-of-pocket expenses.

VSP Enhanced Advantage Plan patients receive a client-defined frame allowance, which 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 VSP Enhanced Advantage Plan frame dispensing and the wholesale cost up to their wholesale allowance, plus collect any overage according to our frame overage procedures.

Note:

We’ll only cover frames when the lenses meet the minimum prescription criteria, unless your patient is eligible for plano lenses.

Most patients with a VSP Enhanced Advantage Plan will have an extra $20 on top of their frame allowance when they select Marchon^® or Altair^® frames. Look for the retail / wholesale allowances for Marchon/Altair and all other frames indicated on the Patient Record Report at authorization.

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.

Other Frame Details

Bill all frames as “doctor supplied” since we’re paying you directly. Your practice is responsible for paying the lab for any lab-supplied frames.

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.

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. Check the Patient Record Report for the patient's specific type of coverage and contact lens allowances. Refer to Contact Lens Benefits in the VSP Manual for more information.

Many clients provide coverage for Low Vision. Refer to the Low Vision section in the VSP Manual for more information.

The benefits below are considered a private transaction between you and your patient. Your patient is fully responsible for payment.

Exam Services

• Charge 80% of U&C on additional eye exams, including if only a refraction is performed.
• Is unlimited for 12 months on or following the date of the last eye exam.

Retinal Screening Value Added Feature

• Patients are eligible for routine retinal screening as a value added feature to complement their WellVision Exam^® benefit.
• Retinal screening: patients pay $39 or your U&C fee, whichever is lower.
• Please see the Retinal Screening section of the VSP Manual for more information. 

Glasses

Charge 80% of U&C for additional materials when complete pairs of prescription glasses and non-prescription sunglasses and blue light filtering glasses are dispensed within 12 months of the exam. This 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 80% of U&C fee.
• Applies to prescription and non-prescription lenses.
• Doesn’t apply to cleaning products or repairs of prescription lenses or frames.

Note:

If a patient has coverage for lenses every 12 months and a frame every 24 months, charge 80% of U&C for the frame in the year when the patient is eligible for lenses but not for a frame.

Contact Lenses

Charge 85% of U&C on contact lens services. This benefit:

• Is subtracted from your U&C fee for evaluation, fitting, and follow-up services for prescription contact lenses.
• Is unlimited for 12 months on or following the date of the 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 80% of U&C.
• Doesn’t apply to lenses, solutions, cleaning products, and service agreements.

VSP Laser VisionCare^SM Program

Please see the Laser VisionCare^SM Program page under Plans & Coverages for plan details.

The VSP Enhanced Advantage Plan may also be sold with the following supplemental plans. Doctors are paid VSP Enhanced Advantage fees for the materials dispensing.

Enhanced Advantage Computer VisionCare^SM Plan

Note: If your patient chooses a covered lens enhancement, there’s no charge and you’ll receive the VSP Enhanced Advantage Plan covered service fee. If your patient selects any other lens enhancements, charge the patient according to the VSP Enhanced Advantage Plan Lens Enhancement Chart or 80% of your U&C fees, whichever is lower. You’ll be charged back the VSP Enhanced Advantage Plan lab fee for those lens enhancements.

See the VSP Computer VisionCare Plan section of the VSP Manual for more information.

Enhanced Advantage Additional Pair

Note: If your patient chooses a covered lens enhancement, there’s no charge and you’ll receive the VSP Enhanced Advantage Plan covered service fee. If your patient selects any other lens enhancements, charge the patient according to the VSP Enhanced Advantage Plan Lens Enhancement Chart or 80% of you U&C fees, whichever is lower. You’ll be charged back the VSP Enhanced Advantage Plan lab fee for those lens enhancements.

Reminder: Obtain a separate authorization for these plans and follow the plan information provided on the authorization.

Claims may be submitted on eClaim or on paper. See the Submitting Claims section in the VSP Manual for details.

See Services Subject to Review/Audit for information regarding material record keeping requirements.

Advantage Exam Plus Plan & Advantage Exam Plus With Allowances Plan

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.

Note:

• Progressive lenses are reimbursed at the bifocal allowance.
• For patients with combined allowances, bill all services at the same time so your patients get their full benefits. Remaining allowances can’t be carried forward. The combined allowance applies to only one set of services. Your patients may use their benefits for lens, lens enhancement and frame or contact lens fitting/materials.

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.

Lab

Refer to the Using Our Contract Lab System page in the VSP Manual.

Online eClaim Submission: Submit orders to any contract lab through eClaim. Include all prescription information. You can choose any lab on the VSP National Contract Lab list.

Paper Claims: Submit your orders to any contract lab on the VSP National Contract Lab list.

The Doctor Service Report on Eyefinity will show the selected lab's contact information for each submitted order. The Lab Packing Slip also shows this information.

First-Time Doctor Redos—Lab Finished Lenses

You may need to remake a patient’s lenses to meet their needs. Refer to First-Time Doctor Redos in the VSP Manual for instructions.

You can only use non-contract labs in emergencies. VSP monitors the use of non-contract labs and they may only be used in the situations below.

Examples of emergencies include:

• Loss, theft, or breakage of prescription eyewear when your patient doesn’t own an alternate pair and can’t wear contact lenses
• Situations where your patient can’t function at work or school and doesn’t have another pair of glasses or contact lenses
• Patients whose safety and well-being will be jeopardized without the immediate delivery of their prescription eyewear

Emergency situations don’t include:

• Instances where faster turn-around time is requested to accommodate trips, vacations, or other discretionary events
• Providing faster service when your patient has another functional pair of glasses or contacts

Important! 

You must document the emergency that requires the use of Non-Contract Labs. Inappropriate use of Non-Contract Labs will result in the denial of services and materials.

To submit a claim when a non-VSP lab is used, select Non-IDC Lab Invoice (Lab 0100) from the pull-down menu in the Lab Selection box on eClaim or write “Non-IDC Lab Invoice (Lab 0100)” in the Special Instructions area of the Materials Invoice. When submitting an emergency claim, please specify the emergency reason. Selecting an emergency reason is for documentation purposes; not selecting a reason does not remove the emergency requirement.

All Lab invoices must be kept for a minimum of seven (7) years. Failure to keep Lab invoices may result in the denial of services and materials.

Lab invoices from an outside private lab must include the following:

• Patient name
• Date ordered/date completed
• Rx
• Lens enhancements
• Style and frame type, including make and model

You’ll be responsible for the entire cost of the lab bill and should pay the lab on a private-transaction basis. Don’t charge the patient for covered lens enhancements, you won’t receive a service fee for covered lens enhancements. For all other lens enhancements, charge the patient according to their plan. You won’t receive a chargeback for these lens enhancements. VSP will pay you an established fee of $10.50 for single vision, $23.50 for bifocal/progressive and $33.50 for trifocal, in addition to your regular dispensing fees. Use your bifocal lens-dispensing fee for progressives. Charge your patient according to the appropriate VSP Advantage Lens Enhancements Chart or your adjusted U&C fee (whichever is lower). Don’t balance-bill the patient.

All emergency orders are subject to review. When a claim is found to be incorrect, payments for material services will be reversed.

Important! 

Always verify orders upon receipt by checking all lab lens enhancement codes.

Uncut lenses can only be processed in the case of an emergency. Submit as a private order. The lab will bill their U&C fees. This should only be done on very rare occasions.

Submitting Claims/Billing & Reimbursement

Submit claims just as you do for VSP Signature Plan claims. For additional information, refer to Submitting Claims in the VSP Manual.

•  You may bill eye 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 the eye exam, 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.

Note: 

When billing progressive lenses, bill your U&C fee on two lines—one for the base bifocal lenses and the second for the progressive add-on.

Reimbursement is made according to the current Advantage Network Fee Schedule. View the Advantage Network Fee Schedule on VSPOnline by selecting Administration and Practice/Doctor Updates from the menu, then clicking the View or Update Fees link.

Note: 

Only Practice Administrators can view the Professional Fee Schedules. If you aren’t able to access the fee schedule, contact Eyefinity at 877.448.0707.

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.

Advantage Network COB Secondary Allowances

Secondary allowances are cumulative.

Other Secondary Allowances:

• For patients with an Elective Contact Lens Benefit, refer to the Patient Record Report for the contact lens allowance. (Note: A covered-in-full contact lens exam does not have secondary COB dollar value).
• For patients with allowance plans, refer to the Patient Record Report for the material allowance.
• You can coordinate the secondary exam allowance with the exam, refraction and/or retinal screening out-of-pocket expense from the primary plan.

Advantage Network Coordination of Benefits

With the exception of the secondary allowances, the VSP Advantage Plan, VSP Enhanced Advantage Plan and VSP Essentials Plan COB guidelines are the same as the VSP Signature Plan. For additional information, see Coordination of Benefits in the VSP Manual.

The following table shows you how to use the secondary plan to coordinate benefits based on your network participation.

VSP Advantage Plan Lens Enhancement Charts

September 1, 2024 VSP Advantage Lens Enhancements Chart

June 27, 2023 VSP Advantage Lens Enhancements Chart

September 1, 2024 VSP Enhanced Advantage Lens Enhancements Chart

December 31, 2023 VSP Enhanced Advantage Lens Enhancements Chart

Blue Cross of Idaho

The following client details apply to Blue Cross of Idaho True Blue and Secure Blue Medicare Advantage plan patients only (does not include True Blue HMO SNP). Refer to VSP Advantage Plan section for complete coverage details not listed below.

Please note:

VSP currently covers the Blue Cross of Idaho Medicare Supplement plan members under a Choice Exam Plus plan coverage. This will not change.

Lenses

Spectacle lens coverage under the VSP Advantage Plan is designed to provide necessary lenses covered in full, including single vision, bifocal, trifocal, or lenticular lenses in plastic or glass. You’ll receive your Advantage Plan lens dispensing fee for covered lenses.

Lens Enhancements

Members are covered for standard progressives, scratch coating and UV protection. If a patient chooses a covered lens enhancement, you’ll receive the Advantage Plan covered service fee.

If your patient selects a non-covered lens enhancement, charge the patient according to the VSP Advantage Network Lens Enhancements Chart.

Lab

All orders must be sent to VSPOne^TM Columbus. In--office finishing equipment or stock lenses may not be used.

Only in an emergency situation may a private lab be used. See Using Non-Contract Labs for more information. If a non-contract lab is used for an emergency situation, the non-Genesis frame allowance would apply.

Covered Frame

Frames from the Altair^® Genesis collection is covered for patients and will be lab supplied though VSPOne™ Columbus. You’ll receive a $19 frame dispensing fee. To ensure correct frame dispensing payment, enter both wholesale and retail frame amounts and choose lab supplied frame option. Genesis frames are fully covered when a complete pair of prescription glasses (lenses and frame) is ordered. Genesis frame only orders are a private transaction and the frame will not be covered by VSP.

You can also use Genesis frames to meet the needs of non-Blue Cross of Idaho patients. Order frames through Altair just as you do today. To inquire or request Genesis frames, contact Altair at 800.505.5557.

Other Frames

A patient has the option of supplying their own frame or purchasing a non-Genesis frame from you. The non-Genesis retail frame allowance is $50. We’ll pay you up to 55% of the patient’s retail frame allowance. When the frame exceeds the retail allowance, charge the patient 80% of the retail price exceeding the allowance. Regardless of the frame brand that’s purchased, the benefit for lenses will still follow Advantage Plan pricing (see Lenses section above). In-office finishing equipment or stock lenses may not be used.

Contact Lenses

Patients may select contact lenses instead of glasses. Please refer to the Patient Record Report for details.

Blue Cross Blue Shield of South Carolina Medicare Advantage

The following client details apply to Blue Cross Blue Shield Medicare Advantage (PPO and HMO patients only). Refer to VSP Advantage Plan section for complete coverage details not listed below.

Lenses

Spectacle lens coverage under the VSP Advantage Plan is designed to provide necessary lenses covered in full, including single vision, bifocal, trifocal, or lenticular lenses in plastic or glass. You’ll receive your Advantage Plan lens dispensing fee for covered lenses.

Lens Enhancements

If your patient selects a non-covered lens enhancement, charge the patient according to the VSP Advantage Network Lens Enhancements Chart.

Lab

All orders must be sent to VSPOne^TM Columbus. In--office finishing equipment or stock lenses may not be used.

Only in an emergency situation may a private lab be used. See Using Non-Contract Labs for more information. If a non-contract lab is used for an emergency situation, the non-Genesis frame allowance would apply.

Covered Frame

Frames from the Altair^® Genesis collection is covered for patients and will be lab supplied though VSPOne™ Columbus. You’ll receive a $19 frame dispensing fee. To ensure correct frame dispensing payment, enter both wholesale and retail frame amounts and choose lab supplied frame option. Genesis frames are fully covered when a complete pair of prescription glasses (lenses and frame) is ordered. Genesis frame only orders are a private transaction and the frame will not be covered by VSP.

You can also use Genesis frames to meet the needs of non-Blue Cross Blue Shield of South Carolina patients. Order frames through Altair just as you do today. To inquire or request Genesis frames, contact Altair at 800.505.5557.

Other Frames

A patient has the option of supplying their own frame or purchasing a non-Genesis frame from you. The non-Genesis retail frame allowance is $50. We’ll pay you up to 55% of the patient’s retail frame allowance. When the frame exceeds the retail allowance, charge the patient 80% of the retail price exceeding the allowance. Regardless of the frame brand that’s purchased, the benefit for lenses will still follow Advantage Plan pricing (see Lenses section above). In-office finishing equipment or stock lenses may not be used.

Contact Lenses

Patients may select contact lenses instead of glasses. Please refer to the Patient Record Report for details.

Moda Health Medicare Advantage

The following client details apply to Moda Health Medicare Advantage (Moda Health PPO and Moda Health Plan Medicare Supplement patients only). Refer to VSP Advantage Plan section for complete coverage details not listed below.

Lenses

Spectacle lens coverage under the VSP Advantage Plan is designed to provide necessary lenses covered in full, including single vision, bifocal, trifocal, or lenticular lenses in plastic or glass. You’ll receive your Advantage Plan lens dispensing fee for covered lenses.

Lens Enhancements

Members are covered for standard progressives, scratch coating and UV protection. If a patient chooses a covered lens enhancement, you’ll receive the Advantage Plan covered service fee. If your patient selects a con-covered lens enhancement, charge the patient according to the VSP Advantage Network Lens Enhancements Chart.

Lab

All orders must be sent to VSPOne^™ Columbus. In--office finishing equipment may not be used.

Only in an emergency situation may a private lab be used. See Using Non-Contract Labs for more information. If a non-contract lab is used for an emergency situation, the non-Genesis frame allowance would apply.

Covered Frame

Frames from the Altair^® Genesis collection are covered for patients and will be lab supplied through VSPOne™ Columbus. You’ll receive a $19 frame dispensing fee. To ensure correct frame dispensing payment, enter both wholesale and retail frame amounts and choose lab supplied frame option. Genesis frames are fully covered when a complete pair of prescription glasses (lenses and frame) is ordered. Genesis frame only orders would be a private transaction and the frame will not be covered by VSP.

You can also use Genesis frames to meet the needs of non-Moda Health Plan patients. Order frames through Altair just as you do today. To inquire or request Genesis frames, contact Altair at 800.505.5557.

Other Frames

A patient has the option of supplying their own frame or purchasing a non-Genesis frame from you. The non-Genesis retail frame allowance is $50. We’ll pay you up to 55% of the patient’s retail frame allowance. When the frame exceeds the retail allowance, charge the patient 80% of the retail price exceeding the allowance. Regardless of the frame brand that’s purchased, the benefit for lenses will still follow Advantage Plan pricing (see Lenses section above). In-office finishing equipment or stock lenses may not be used.

Contact Lenses

Patients may select contact lenses instead of glasses. Please refer to the Patient Record Report for details.

Summit Health Plan

The following client details apply to Summit Health Plan patients only. Refer to VSP Advantage Plan section for complete coverage details not listed below.

Lenses

Spectacle lens coverage under the VSP Advantage Plan is designed to provide necessary lenses covered in full, including single vision, bifocal, trifocal, or lenticular lenses in plastic or glass. You’ll receive your Advantage Plan lens dispensing fee for covered lenses.

Lens Enhancements

Members are covered for standard progressives, scratch coating and UV protection. If a patient chooses a covered lens enhancement, you’ll receive the Advantage Plan covered service fee.

If your patient selects a non-covered lens enhancement, charge the patient according to the VSP Advantage Network Lens Enhancements Chart.

Lab

All orders must be sent to VSPOne^™ Columbus. In--office finishing equipment or stock lenses may not be used.

Only in an emergency situation may a private lab be used. See Using Non-Contract Labs for more information. If a non-contract lab is used for an emergency situation, the non-Genesis frame allowance would apply.

Covered Frame

Frames from the Altair^® Genesis collection are covered for patients and will be lab supplied through VSPOne™ Columbus. You’ll receive a $19 frame dispensing fee. To ensure correct frame dispensing payment, enter both wholesale and retail frame amounts and choose lab supplied frame option. Genesis frames are fully covered when a complete pair of prescription glasses (lenses and frame) is ordered. Genesis frame only orders would be a private transaction and the frame will not be covered by VSP.

You can also use Genesis frames to meet the needs of non-Moda Health Plan patients. Order frames through Altair just as you do today. To inquire or request Genesis frames, contact Altair at 800.505.5557.

Other Frames

A patient has the option of supplying their own frame or purchasing a non-Genesis frame from you. The non-Genesis retail frame allowance is $50. We’ll pay you up to 55% of the patient’s retail frame allowance. When the frame exceeds the retail allowance, charge the patient 80% of the retail price exceeding the allowance. Regardless of the frame brand that’s purchased, the benefit for lenses will still follow Advantage Plan pricing (see Lenses section above). In-office finishing equipment or stock lenses may not be used.

Contact Lenses

Patients may select contact lenses instead of glasses. Please refer to the Patient Record Report for details.

California State University (CSU) Client Details

Computer Vision Care (CVC)

Only eligible California State University employees are covered for a Computer VisionCare (CVC). Dependents are not covered. CSU Retirees benefits exclude CVC coverage.

To receive a CVC benefit, employees must obtain a VSP Computer VisionCare Confirmation Form from their CSU campus benefits office and present the form to you at the time of service. Keep a copy of the VSP Computer VisionCare Confirmation Form signed by the patient in their file.

You’ll be reimbursed according to the Advantage Plan Professional Fee Schedule for CVC materials dispensed and your Advantage Plan fees for CVC exams. Refer to the CVC section of the VSP Manual for additional information.

VSP Computer Visioncare Confirmation Form

Advantage Network Fee Schedules

Doctors can access their Advantage Fee Schedule on VSPOnline by going to www.eyefinity.com/goto/fees, clicking on “View Your Fees,” and then clicking on the “Advantage” button.