VSP Choice Plan^®

This supplement to the VSP Manual provides information regarding coverage for VSP patients with the VSP Choice Plan, VSP Choice Exam Plus Plan^SM, Choice Access, and supplemental plans.

Only participating Choice Network doctors can provide services to VSP Choice Plan patients.

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.

Copay information is provided when you obtain an 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.

Choice Coordination of Benefits

With the exception of the secondary allowances, the VSP Choice 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.

Exam Coverage

Covered comprehensive eye exams are generally available to patients 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.

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.

Your assigned VSP Choice Plan^® eye exam fees are based on levels of service. 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.

Note: 

Avoid reduced reimbursement. Bill separately for refraction (92015). Your Choice Network Fee Schedule lists your refraction fee.

Materials Coverage

Under the VSP Choice Plan^®, 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.

Note: 

Some patients have a covered in full frame allowance. For these plans, you receive your frame dispensing and the wholesale cost.

Most patients with a VSP Choice Plan 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 Report 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.

Patients are also eligible for savings on additional services and materials (see Value-Added Benefits below).

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.

Note: 

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

• 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)

Note:

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 must be ±0.50 diopter or greater in at least one eye. If not, you can apply one of the following exceptions:
— Necessary prism is 0.50 diopter or greater in at least one eye.
— Anisometropia is 0.50 diopter or greater.
— Cylinder power is ±0.50 diopter or greater.

If your patient selects a lens enhancement that has a copay, collect the lens enhancement copay directly from the patient. You’ll be charged the VSP Choice Plan charge-back fee for those lens enhancements.

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

If your patient chooses a covered lens enhancement, you’ll receive the Choice 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 or patients with the Federal Plan.

To offer more customized coverage to clients and members, we’ve developed 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.

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 this coverage. 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.

Charge 80% of U&C on additional eye exams.

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. 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 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.

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.

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.

• 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 PRK 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 see the Laser VisionCare program page on VSPOnline for information on how to participate or for a list of participating facilities.

• 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.

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

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 Choice 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 Choice Plan Lens Enhancements Charts. You’ll be charged back the VSP Choice Plan lab fee for those lens enhancements.

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

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 Choice Plan Lens Enhancements Charts 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 Choice Plan Lens Enhancements Chart. You’ll be charged back the VSP Choice Plan lab fee for those lens enhancements.

Doctors are paid Choice 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.

VSP EasyOptions

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

VSP Elements Program^®

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

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.

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 VSP Choice 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 VSP Choice Plan^® claims following the same procedure as VSP Signature Plan^® claims. For additional information, refer to the Submitting Claims section in the VSP Provider Reference Manual.

• 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.

Note: 

Bill your U&C fee on two lines for progressive lenses; one for the base bifocal lenses and the second for the progressive add-on.

Reimbursement is made according to the current VSP Choice Plan Fee Schedule. View the VSP Choice Plan Fee Schedule on VSPOnline under Administration, by clicking on Practice/Doctor Updates and then View or Update Fees.

Note:

Only Practice Administrators can view the Professional Fee Schedules. If you can’t 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.

ADP TotalSource

Instead of using their material benefit for prescription eyewear (including lens, frame, and contact lenses), eligible patients can choose to use their benefit toward approved Laser Vision Care (LVC) services  (LASIK, Custom LASIK, Bladeless LASIK, PRK, Custom PRK, SMILE or Contoura)..

Eligible patients will have a $150 LVC allowance every plan year. The allowance amount applies to both eyes. The patient must be eligible for materials to receive LVC services. The patient will still be eligible for the standard LVC discounts.

After surgery, patients may use their frame allowance (if eligible) for sunglasses. Coverage for sunglasses is not allowed in the same plan year as LVC services.

BCBSM-MESSA (Blue Cross Blue Shield of Michigan - MESSA)

Providers will be able to locate MESSA members in the VSP system using their full SSN or by searching by name, date of birth, and the last four digits of their SSN. Should MESSA members present their Blue Cross/MESSA insurance card, staff should use it as identification only. MESSA members’ Enrollee ID’s are not going to be used as an identifier in the system.

Follow VSP’s standard COB process effective January 1, 2021. When paying secondary on a MESSA Choice plan, use the standard Choice COB secondary allowances, less any applicable copay. For additional information, see Coordination of Benefits in the VSP Manual.

Important!

Effective January 1, 2021, MESSA has added 3 additional Choice Plans MESSA Vision, MESSA Vision Enhanced, and MESSA Vision Preferred. MESSA members will have the following Choice Plans available in addition to their existing Signature Plans*.

*Please refer to the Signature PRM for plan benefit information.

Note #1:

Standard contact lens benefit. Add your U&C fees for materials then add your professional fee for contact lens (discounted by 15%) and apply your patient’s allowance.

Cleveland Bakers & Teamsters H&W Fund Client Details

The Cleveland Bakers & Teamsters H&W Fund provides the following custom benefits:

Members also have an up to $50 total allowance for any individual or combination of the following lens enhancements ordered on the primary Choice Plan benefit:

Anti-reflective coatings, Polycarbonate lenses, Photochromic or Tinted lenses, Progressive lenses, Scratch-resistant coating, UV coating.

The $50 total lens enhancement allowance is available every other calendar year for all relationships except Children under 12 who are eligible every calendar year.

When the patient selects any individual or combination of these lens enhancements, they receive an additional up to a $50 total allowance towards their OOP costs:

• Anti-reflective coatings
• Polycarbonate lenses
• Photochromic or Tinted lenses
• Progressive lenses
• Scratch-resistant coating
• UV coating

Calculate the patient’s OOP expenses for each of the covered lens enhancements ordered above. Patient costs are based on the Choice Plan cost-controls as indicated on the primary authorization.

• Determine the total OOP amount and if it’s $50 or more, deduct the full $50 allowance and bill the patient the difference. If less than $50, then the patient will have no OOP cost for the enhancement(s).
• You will be reimbursed either the $50 allowance or the patient’s OOP expense, whichever is less.

Examples

For Up to $50 Allowance

To receive reimbursement of the lens enhancement allowance, pull the authorization for Additional Pair. It will reflect eligibility for Lenses only.

For Contact Lens Services

If Contacts shows NO for eligibility, contact VSP to determine if the patient is eligible for Contact Lens Services via Interim Benefits.

For Up to $50 Allowance

Bill the Lenses only benefit and indicate the patient’s Total OOP expenses as your dispensing fee. See example above for assistance with calculating.

For Up to $50 Allowance

In the drop-down menu, select Lab 100 for the Additional Pair benefit only.

Reimbursement of the up to $50 allowance will be paid under the Additional Pair benefit which you may need to tie back to the patient's primary Choice Plan EOP for reconciliation.

For assistance concerning these custom benefits, contact VSP at 800.615.1883.

Cigna Healthy Rewards—Vision Network Savings Program

Important! 

If updates are made to the VSP Choice Access Plan, those changes will apply to Cigna’s Vision Network Savings Program.

VSP administers the Vision Network Savings Program under Cigna's Healthy Rewards Program. The program provides savings for routine vision services and materials to all Cigna members through a Cigna Vision provider.

The plan is a VSP Choice Access plan with regional pricing on certain vision services and materials (see below for savings and prices). Prices are determined regionally, and services are available through VSP's Choice Network of doctors. Savings may be used an unlimited number of times during the patient's enrollment as a Cigna member.

There are no authorizations or claims to file—just bill the patient directly after applying the appropriate savings and regional prices.

• All Cigna medical, dental, vision, pharmacy, behavioral health, and voluntary plan members are eligible for the program and can receive savings on routine vision services and materials from a Cigna Vision provider.
• Eligibility for the Vision Network Savings Program will not be available online—you won’t be able to obtain an authorization or file a claim with VSP.
• If the patient has routine coverage available, please use that coverage first.
• The savings are available when patients pay privately for services and materials—they aren’t combined with any other routine vision coverage.

Please Note: 

Some Cigna members may have routine benefits directly through Cigna. If benefits can't be verified with VSP, apply the Vision Network Savings Program benefits, charge the patient, and advise him or her to contact Cigna to find out if he or she can submit a claim directly to Cigna.

Important! 

There are no authorizations or claims to file—just bill the patient directly.

• Charge patient 80% of U&C for exam fees or the regional exam pricing listed below for your region.
• Compare and charge the patient the lower of the two.
• Provide the level of exam needed to determine your patient’s visual health status.
• Savings only applies to services and procedures included in a WellVision Exam. It doesn’t apply to additional diagnoses and treatment.

Eligible patients get savings on frames, lenses, lens enhancements, and non-prescription sunglasses and blue light filtering glasses. Use professional judgment when evaluating prescriptions from another doctor.

Please provide the following savings and follow the regional pricing when providing services to Cigna members through the Vision Network Savings Program.

Savings of 25% on the retail price of the frame.

• For all lenses, charge patients 80% of U&C fees or the regional lens prices listed below for your region.
• Compare and charge the patient the lower of the two. There are also region specific pricing for single vision, bifocal, and trifocal lenses.
• Refer to the chart below to determine the appropriate pricing based on your location.

Important! 

If updates are made to the VSP Choice Access Plan, those changes will apply to Cigna’s Vision Network Savings Program.

Charge patients 80% of U&Cor the prices for your region as indicated below. Patients should be charged the lower of the two amounts.

• Polycarbonate: Charge 80% of U&C fees, not to exceed $40.
• Standard Anti-Reflective Coating (Code QM Only): Charge 80% of U&C fees, not to exceed $45.
• All other Anti-Reflective Coatings (refer to the Product Index): Charge 80% of U&C fees.
• Standard Scratch Coating (Factory Applied Only): Charge 80% of U&C fees, not to exceed $15.
• UV Coating: Charge 80% of U&C fees, not to exceed $15.
• Standard Progressive (Code KA): 80% of U&C fees, not to exceed $55 (only the amount over the base lens-flat top 28)
• Premium and Custom Progressive(Code FA, JA, NA, OA): Charge 80% of additional U&C cost for the progressive (only the amount over the base lens—flat top 28).
• Higher Powers: Charge 80% of additional U&C cost for high powers lenses.
• All Other Lens Enhancements & Features: Charge 80% of U&C fees.

Progressive Lenses

You can use this example to help determine what to bill a patient for a progressive lens. In this example, the practice is located in Arkansas (or Region 4).

*Important!

Please refer to the Lenses section above to determine the appropriate bifocal maximum for your region based on your office location.

• Charge patients 85% of U&C.

• Charge patients as usual.

• Charge 80% of U&C.

Lab work can be done on a private invoice basis using any lab, including in-office labs.

LASIK discounts are not included through the Vision Network Savings Program administered by VSP. Please have patients contact Cigna Member Services at the phone number or Web site on their ID card for more information.

Cigna Vision

VSP is one of Cigna Vision’s routine vision care plan administrator. Cigna Vision plans typically cover a full eye exam, less a copay. We’ll indicate specific plan information, coverage of materials, reimbursements, and copays, if any, on the Patient Record Report (a.k.a. authorization). Cigna Vision routine plans are administered through the Choice Network. If you are not able to locate coverage under VSP, please refer member to Cigna to determine if coverage is offered under alternate vision vendor.

Note:

If members have questions regarding their benefits, please refer them to Cigna Vision Customer Service at 877.478.7557. Use your current VSP eligibility, authorization, and claims processes for Cigna Vision patients, including calling VSP for questions at 800.615.1883.

Please check eligibility for routine services with VSP first for Cigna members to ensure claims are billed to the appropriate insurance carrier as some members may have routine benefits directly through Cigna. If benefits can’t be verified with VSP, apply the Cigna Healthy Rewards-Vision Network Savings Program savings, charge the patient, and advise him or her to contact Cigna to find out if the claim can be submitted directly to Cigna.

Some Cigna Vision members may also have dual coverage. They may have a full service VSP plan and a Cigna Vision Choice Exam Plus plan. Comment codes will alert you that the member may have dual coverage. If dual coverage does exist, check eligibility using the last 4 digits of the primary member’s SSN, instead of the Cigna ID number.

Cigna Vision has some exceptions to coverage that are slightly different than our other plans. The Patient Record Report (a.k.a. authorization) will indicate the following exceptions:

Polycarbonate lenses

These lenses are covered for children under the age of 19. The authorization will indicate them as a covered lens enhancement.

Oversize lenses

These lenses are covered regardless of the eye size.

Value Added Benefits

Cigna Vision members qualify to receive a savings on exams and contact lens services through the Cigna Healthy Rewards Vision Network Savings Program. Members also receive lenses and lens enhancements at 80% of U&C, and frames at 75% of U&C even when a complete pair of glasses isn’t ordered. Please refer to the Cigna Healthy Rewards-Vision Network Savings Program Client Detail Page for more detailed information.

Allowance Plans - Remaining Allowance

Cigna Vision members with an Exam Plus or Access Indemnity plan, with a combined material allowance, can apply any unused portion of the material allowance at a later date, within the same eligibility period (i.e. calendar year), to additional materials or services. Some exceptions may apply. See the Patient Record Report for any client exceptions Members can’t carry forward balances from a past eligibility period. Call VSP at 800.615.1883 to determine available allowances and to obtain an authorization.

Material copays don’t apply to visually necessary contact lenses. Don’t collect material copays from patients receiving visually necessary contact lenses, unless indicated in special comments.

We reimburse for services or materials provided to Cigna Vision members four times a month. Your normal Explanation of Payment (EOP) shows your Cigna Vision patients. In addition to your standard EOPs, you may receive an EOP for additional payment cycles, if you billed VSP for services or materials for a Cigna Vision Patient. For questions, call VSP at 800.615.1883.

The following Cigna Vision clients have unique exceptions as indicated below.

Progressive Lenses

This plan has a $70 allowance for progressive lenses, with a $40 copay. The authorization includes a comment code, indicating the allowance amount. If progressive lenses are ordered, subtract the copay from your adjusted U&C fees, and then subtract the $70 progressive allowance. Bill your patient the remaining balance. You may use any lab on a private invoice basis.

Lab Selection Instructions

To choose a lab on eClaim:

• VSP contract lab - to send the order to a VSP contract lab, simply enter the lab ID number in the lab ID field in eClaim. This is a private transaction between your office and the lab. You’ll receive a lab bill.
• Non-VSP contract lab - to send the order to a non-VSP contract lab, choose lab 100 from the eClaim drop down menu. Also submit your lab order directly to the lab of your choice. eClaim won’t forward your order to any lab. This is a private transaction between your office and the lab. You'll receive a lab bill.

Lens Enhancements

If your patient selects progressive lenses and also orders covered lens enhancements, don’t charge your patient for the lens enhancements. You’ll receive both the covered service fee and the VSP Choice Plan chargeback fee (we usually pay this fee to the lab) for the covered lens enhancement(s) provided. Please refer to the VSP Choice Plan Lens Enhancements Chart (see exception below).

Exception: rimless mount and pink 1 and 2 tints are considered part of the allowance. No additional payment will be made for these enhancements.

If other lens enhancements are ordered with the progressive lens, charge the patient 80% of your U&C.

Important! 

Apply these special handling procedures to patients selecting progressive lenses. Follow normal plan procedures for any other selected lens type.

Contact Lens Coverage

In addition to a routine WellVision exam, patients are also covered for contact lens services (fitting and evaluation). Patients can choose to use their benefits towards an exam, contact lens services (fitting and evaluation) and either glasses (lens and frame) or contact lenses.

The contact lens allowance is based on the type of contact lenses that are dispensed. For non-disposable contacts, the allowance is $180. For disposable contacts, the allowance is $230.

Contact lens materials are eligible once per lifetime. The patient can receive contact lens materials and a frame in the same eligibility period.

Visually Necessary Contact Lenses

This plan has a $230 allowance for necessary contact lenses. Follow normal procedures to determine if the patient meets the visually necessary contact lens criteria and bill your patient the remaining balance. The patient is covered in full for contact lens services (fitting and evaluation). Use the patient's Additional Pair benefit to bill the contact lens services.

Contact lens coverage

In addition to a routine WellVision exam, patients are also covered for contact lens services (fitting and evaluation). Patients can choose to use their benefits towards an exam, contact lens services (fitting and evaluation), and either glasses (lens and frame), or contact lenses.

Visually Necessary Contact Lenses

This plan has a $170 allowance for both visually necessary contact lenses and elective contact lenses (ECL). If your patient requires visually necessary contact lenses, bill as elective contact lenses. Apply the allowance to 85% of your U&C for the contact lens services (fitting and evaluation) fees and your U&C for contact lens material fees. Bill your patient the remaining balance.

Progressive lenses

All progressive lenses are covered with a $40 copay.

Claim Submission

Please include all services and/or materials, when submitting claims for SEIU members, including those not covered by their Cigna Vision benefits (additional pairs, etc.). The charges can be added to the FSA field on eClaim. Refer to the Flexible Spending Account section in the VSP Manual for more information.

SEIU - Union Plan

Visually Necessary Contact Lenses

This plan has a $40 allowance for both visually necessary contact lenses (NCL) and elective contact lenses (ECL). If your patient requires visually necessary contact lenses, bill as elective contact lenses. Apply the allowance to 85% of your U&C for the contact lens services (fitting and evaluation) fees and your U&C for contact lens material fees. Bill your patient the remaining balance.

Progressive lenses

All progressive lenses are covered with a $50 copay.

Claim Submission

Please include all services and/or materials, when submitting claims for SEIU members, including those not covered by their Cigna Vision benefits (additional pairs, etc.). The charges can be added to the FSA field on eClaim. Refer to the Flexible Spending Account section in the VSP Manual for more information.

Progressive lenses

This plan has a $105 allowance for progressive lenses. The authorization includes a comment code, indicating the allowance amount. If progressive lenses are ordered, subtract the allowance from 80% of your U&C fees. Bill your patient the remaining balance. You may use any lab on a private invoice basis.

Lab Selection Instructions

To choose a lab on eClaim:

• VSP contract lab - to send the order to a VSP contract lab, simply enter the lab ID number in the lab ID field in eClaim. This is a private transaction between your office and the lab. You'll receive a lab bill.

Non-VSP contract lab - to send the order to a non-VSP contract lab, choose “lab 100” from the eClaim drop down menu. Also submit your lab order directly to the lab of your choice. eClaim won't forward your order to any lab. This is a private transaction between your office and the lab. You'll receive a lab bill.

Lens Enhancements

If your patient selects progressive lenses and also orders any covered lens enhancements, don't charge the patient for the lens enhancements. You’ll receive both the covered service fee and the VSP Choice Plan chargeback fee (we usually pay this fee to the lab) for the covered lens enhancement(s) provided. Please refer to the VSP Choice Plan Lens Enhancements Chart. Please note, if there are no service fees or charge back amounts listed (i.e. rimless mounting and pink tints 1&2), the lens enhancement is considered covered in the allowance and no additional payment will be made

If other lens enhancements are ordered with the progressive lens, charge the patient 80% of U&C for the lens enhancement.

Important! 

Apply these special handling procedures to patients selecting progressive lenses. Follow normal plan procedures for any other selected lens type.

Allowances

This plan has a $999.98 combined allowance for any combination of exam, lenses, lens enhancements, frames, and contacts. Apply allowance to adjusted U&C for exam, glasses, and contact lens services. You may bill the patient the remaining balance. Remaining balance may be used later if not exhausted with first claim. Call VSP Provider Services to determine remaining allowance and issue auth.

Frequency

Member and dependents are available for the full allowance every January 1st of even numbered years. Call VSP Provider Services at 800.615.1883.

Cigna has some clients that cover services in full for members under the age of 19 and/or members 19 and over.

The plans can be VSP Choice, Exam Plus with Allowance, or Access Indemnity. The coverage is identified with a comment code that indicates patients are covered in full for one pair of glasses or a one year supply of disposable contacts or one pair of conventional contacts, including the contact lens services (fitting and evaluation).

Contact lens materials will be reimbursed according to the Covered Contact Lens plan. The contact lens services will be reimbursed at 85% of your U&C fees. Dispensing an annual supply at one time is required under these plans. VSP should only be billed for an annual supply of lenses and shouldn't be billed for additional lenses. Additional lenses should be handled as a private transaction between you and the patient.

Full pair of glasses will be reimbursed at 80% of your U&C fees, including lens enhancements. Covered lens enhancements include - Oversize, UV coating, scratch coating, polycarbonate and tints (solid & plastic gradient).

Commonwealth Care Alliance Client Details

Two pairs of single vision eyeglasses, one for near vision and one for distance vision, are covered in lieu of multifocal eyeglasses only when one or more of the following conditions exists:

• The member's Rx cannot be made into bifocal lenses
• The member is unable to adjust to bifocals
• The member has a disability or is at an advanced age that precludes adjustment of bifocals
• The member's occupation makes bifocals hazardous
• The member has marked facial asymmetry

• DIOPTER CHANGE >= .50 DIOPTERS or
• AXIS CHANGE >= 15 DEGREES or
• PRISM CHANGE >= .50 DIOPTERS

See Interim Benefits in the Plans and Coverages section for more information.

FCA - Stellantis Represented Employees Client Details

(AKA Fiat Chrysler Automotive or Chrysler Stellantis)

FCA - Stellantis Represented Employees receive the following custom benefit provisions:

• $7.50 Copay applies to ECL

15% Discount off CL Materials Overages

• Interim Benefits for Myopia Management of Dependent Children
• Interim Benefits for Type 1 Diabetics

And for the HBU, and NTC Active Unions only, they also access to the Preferred Laser Vision Care benefit every four years.

Patients have an Exam And $90 Contact Lens Allowance with a $7.50 copay plus a 15% discount off contact lens material overages.

This client requires subtracting their $7.50 copay from the total charged, rather than from the contact lens allowance. Subtract copay from total of discounted fitting, evaluation and U&C material charge. Follow instructions below.

First, did the patient receive any contact lens professional services? If no, skip to section: example when only materials are provided.

If yes, then determine whether your total charges (85% of U&C fitting & evaluation plus materials) is more or less than the patient’s $90 contact lens allowance. Then follow the corresponding example within section: examples when both professional services and materials are provided.

Examples – When only Materials are Provided

Examples - When both Professional Services and Materials are Provided

Note: 

Our online Savings Statement will not automatically calculate copays or overages for ECL members of this client.

The FCA - Stellantis Represented Employees have the following interim benefits when benefit criteria are met:

Insulin-dependent diabetics (Type 1) will be eligible for an eye exam every January 1 after last eligible exam covered by the vision plan with a $5 copay. If the exam reveals a prescription change of .50 diopter or more and/or 10 degrees of axis change or more, new lenses will be provided with a $7.50 copay according to vision benefits provided by the plan annually. Ensure you indicate your patient’s Type 1 diabetes in their chart.

Dependent children up to their 19th birthday are eligible to receive a yearly exam with a $5 copay and new lenses, subject to a $7.50 copay with a prescription change of a -.50 diopter or more for.

(For HBU, SBU and NTC Active Unions only)

Total (both eyes) allowance of $350 once every four years, instead of prescription eyewear.

Divisions 3001 – 3006 only - In addition to using their material benefit for prescription eyewear (including lens, frame, and contact lenses), eligible patients may use their benefit toward approved Laser Vision Care (LVC) services (LASIK, Custom LASIK, Bladeless LASIK, PRK, Custom PRK, SMILE or Contoura).

Eligible patients will have a $350 total LVC allowance available once every four (4) plan years. The allowance amount applies to both eyes. The patient may be eligible for materials, in addition to LVC services. The patient will still be eligible for the standard LVC discounts.

Please note: eligibility may not show online. Contact VSP to confirm and/or receive authorization.

To receive an authorization for either Interim Benefits or Preferred Laser Vision Care, contact VSP.

For assistance concerning these custom benefits, contact VSP at 800.615.1883.

Federal Employees Dental and Vision Insurance Program (FEDVIP)

10-digit MEMBER ID Numbers FEDVIP:

As of January 1, 2022, VSP started issuing all FEDVIP members a 10-digit Member ID number. Practices should use this Member ID to authorize benefits for your FEDVIP VSP patients in place of their Social Security Number.

If a patient asks where they can find their 10-digit Member ID, they can simply log in to their vsp.com account as they normally would and navigate to their Member ID card. Their ID card will be updated with this new number, and they can print it at any time.

FEDVIP members with the VSP High Option plan are covered for TechShield^™ anti-reflective (AR) coatings and have a $20 allowance for non-TechShield^™ AR coatings. Review the Patient Record Report and the Patient Lens Enhancement Charges Report to calculate the correct charges, if any.

Prescription eyewear orders for FEDVIP members are fulfilled through a nationwide network that includes VSPOne Optical Technology Centers and more than 50 other contract labs. Based on the materials requested, eClaim at eyefinity.com will display a list of labs available to complete your order. Orders will be routed according to the claim submission date rather than the date of service.

Some FEDVIP members may have routine vision coverage through their health plan.

If the member and provider participate in both FEHB and FEDVIP, the lesser of the contractual plan allowances will prevail. This means the office will need to calculate the cost to the member under each plan; the plan that has the least out-of-pocket cost to the member will be Primary.

Please confirm the health plan information with your patient and verify that the health plan will cover your services.

If the health plan covers:

Exam Only: Bill us as primary for materials. Coordinate benefits for the routine exam per the guidance above to ensure least out-of-pocket cost to the member. If the health plan is determined to be primary, submit a paper claim to us after you receive payment from the health plan, along with a copy of the health plan's explanation of benefits.

Exam and Material: Coordinate benefits for the routine exam and materials per the guidance above to ensure least out-of-pocket cost to the member. If the health plan is determined to be primary, submit a paper claim to us after you receive payment from the health plan, along with a copy of the health plan's explanation of benefits.

If the health plan doesn't cover your services, bill us as primary.

Reimbursements are based on the VSP Choice Plan secondary COB allowance. For more information, refer to the COB Between Health Plans and VSP Plans section of the VSP Manual.

Note: 

If the federal employee’s health benefit (FEHB) plan is an HMO and you’re not a participating provider under that plan, then bill us as primary.

Eyefinity's eClaim will display messages when patients have routine vision coverage through their health plan, indicating that coordination of benefits may apply. The IVR system and faxed authorizations will have similar messages. These messages aren't available for practices using the Practice Management Interface software.

MetLife Vision

Patients will identify their coverage as "MetLife Vision". Most will not be issued a member ID card; however, patients may print their own member ID card at metlife.com.

When you request an authorization, the Patient Record Report will indicate "METLIFE VISION MEMBER" in the Special Information – Group Comments section. Be sure to carefully review the copays, allowances, and covered lens enhancements on the Patient Record Report.

If eligibility is not verified, patient may be enrolled in another MetLife product through Versant Health; either Davis or Superior.

Your practice will request an authorization, submit claims, and be reimbursed just as you would for a VSP Choice Plan^® patient.

Important! 

If the patient provides the program code MET2020 or displays a MetLife VisionAccess Program wallet card, they are eligible for the MetLife VisionAccess Program pricing in lieu of the VSP Choice Plan value-added benefits. (Eligibility for the MetLife VisionAccess Program is not in the system and will not appear on the Patient Record Report.) For details on administering the benefit, please see the MetLife VisionAccess Program page.

Remember, patients won't know that VSP is the third-party administrator for MetLife Vision. Use the MetLife-branded patient forms returned with the authorization or download them from the Forms Library under Administration on VSPOnline.

Practices should call VSP at 800.615.1883 with any questions. Please refer patients with questions to MetLife Vision Customer Service:

• MetLife Vision – Call 855.MET.EYE1 (855.638.3931).
• MetLife VisionAccess Program – Call 800.ASK.4MET (800.275.4638).

Benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. In certain states, availability of MetLife's group vision benefits is subject to regulatory approval.

MetLife VisionAccess Program

VSP administers the MetLife VisionAccess Program, providing MetLife members with benefits for routine vision services and materials through VSP Choice Network providers.

The plan is a VSP Choice Access^® plan with regional pricing on certain vision services and materials. Prices are determined regionally.

There are no authorizations or claims to file—just bill the patient directly after applying the appropriate benefits and regional prices available an unlimited number of times.

Important! 

The MetLife VisionAccess Program is separate from MetLife Vision, although some members may be eligible for both. Be sure to check eligibility on eyefinity.com to see if the patient is also eligible for MetLife Vision. For details on administering the benefit, please see the MetLife Vision page.

• Members who provide the program code MET2020* (or display an optional MetLife VisionAccess Program wallet card) during their office visit are eligible.
• Eligibility for the MetLife VisionAccess Program is not available online—you won’t be able to obtain an authorization or file a claim with VSP.
• If the patient has routine coverage available, please use that coverage first.
• The savings are available when patients pay privately for services and materials; they aren’t combined with any other routine vision coverage.

Important! 

There are no authorizations or claims to file—just bill the patient directly.

Download a printable regional schedule. Your region, as noted at the top of the report, determines the prices for the eye exam and lenses.

• Charge patients 80% of U&C or the price listed in the MetLife VisionAccess Regional Schedule for your region, whichever is lower for eye exam.
• Provide the level of exam needed to determine your patient's visual health status.
• Savings only applies to services and procedures included in a WellVision Exam. It doesn't apply to additional diagnoses and treatment.

Eligible patients receive savings on frames, lenses, lens enhancements, and plano sunglasses. Use professional judgment when evaluating prescriptions from another doctor.

Please provide the following savings or regional pricing, when providing services to patients eligible for the MetLife VisionAccess Program.

Frame

• Charge 75% of U&C for the retail price of the frame.

Lenses

• For all lenses, charge patients 80% of U&C or the price listed in the MetLife VisionAccess Regional Schedule for your region (see above).
• Compare the fee and the regional price; charge the patient the lower of the two.
• There are also region-specific prices for single vision, bifocal, and trifocal lenses. Refer to the MetLife VisionAccess Regional Schedule for your region (see above) to determine the appropriate pricing.

Charge patients 75% of U&C for frames, 80% of U&C for lenses, or the regional pricing as indicated in the MetLife VisionAccess Regional Schedule for your region (see above).

Lens Enhancements

• Polycarbonate: Charge 80% of U&C fees, not to exceed $40.
• Standard Anti-Reflective Coating (Code QM Only): Charge 80% of U&C fees, not to exceed $45.
• All other Anti-Reflective Coatings (refer to the Product Index: Charge 80% of U&C fees.
• Standard Scratch Coating (Factory Applied Only): Charge 80% of U&C fees, not to exceed $15.
• UV Coating: Charge 80% of U&C fees, not to exceed $15.
• Standard Progressive (code KA): Charge 80& of U&C fees, not to exceed $55 (only the amount over the base lens-flat top 28)
• Premium and Custom Progressive (Code JA, FA, NA, OA): Charge 80% of additional U&C cost for the progressive (only the amount over the base lens—flat top 28).
• Higher Powers: Charge 80% of additional U&C cost for high powers lenses.
• All Other Lens Enhancements & Features: Charge 80% of U&C fees.

Progressive Lenses

You can use this example to help determine what to bill a patient for a progressive lens. In this example, the practice is located in Arkansas.

*Important! 

Please refer to the Lenses section above to determine the bifocal price for your region based on your office location.

Contact Lens Exam Services (Fitting & Evaluation)

• Charge patient 85% of U&C fee.

Contact Lens Materials

• Charge patients as usual.

Plano Sunglasses and Blue Light Filtering Glasses

• Charge 80% of U&C fees.

Lab work can be done on a private invoice basis using any lab, including in-office labs.

Refer to the Laser VisionCare section of the VSP Manual for information. Coverage mirrors the VSP Laser VisionCare^SM Program offered with the VSP Choice Access Program.

Practices should call VSP at 800.615.1883 with any questions.

Please refer patients with questions to MetLife VisionAccess Customer Service at 800.ASK.4MET (800.275.4638).

MetLife VisionAccess is a savings program and not an insured benefit. It is provided through VSP Vision Care, Rancho Cordova, CA. VSP is not affiliated with Metropolitan Life Insurance Company or its affiliates.

Note: 

Any changes to VSP Choice Access Plan apply to MetLife’s VisionAccess Program.

Principal Financial Group

All Principal plans are on the Choice Network with participating retails chains, VSP Choice Plan^®, which includes a fully covered VSP WellVision Exam^® and quality prescription eyewear featuring the lowest out-of-pocket costs with our lens enhancements savings and wholesale frame pricing guarantee.

Retirees: Please refer to VSP Vision Savings Pass in the Client Details section for further information.

Current employees and dependents: Please refer to VSP Choice Plan and VSP Exam Plus Plan for further information.

Principal identifies members by a unique nine-digit ID number referred to as a member or privacy ID. Members can find this number on principal.com or on the Principal mobile app.

VSP Eyes of Hope gift certificates ensure adults and children in need, including those affected by disaster, can access quality eye care and prescription glasses at no cost through a local VSP network doctor. The certificates are distributed through our national network of charitable partners, including the American Red Cross, Lions Clubs, National Association of School Nurses, and Prevent Blindness. As a Choice Network doctor, you’ll be reimbursed when you see patients with a certificate. Learn more at vspproviderhub.com/eyes-of-hope.

VSP Eyes of Hope offers two types of charitable gift certificates that provide no-cost eye exams and glasses through Choice Network doctors for adults and children who qualify:

• VSP Eyes of Hope gift certificates are distributed to adults and children in need through national and regional strategic partners and at local outreach events with charitable and community partners throughout the U.S. Gift certificates provide access to an exam, frame, and lenses. People who have coverage for an exam through another means, but not for frames and lenses, can use a gift certificate to get the prescription glasses they need.
• Disaster Relief gift certificates are distributed through the American Red Cross and VSP Eyes of Hope mobile clinics to adults and children who need eye care or have lost or damaged their glasses during a disaster.

Patients have been pre-qualified by a charitable partner to meet program eligibility, and your practice will be reimbursed for the eye care and glasses you provide just as if the patient is a VSP member with a VSP Choice Plan^®. Please review the following information carefully, for details on what is covered.  

If you are not currently a Choice Network provider, please refer the patient back to VSP at 800.877.7195 to find a participating provider.

If you have any questions about the program, call VSP Customer Care at 800.615.1883.

Check Validity

Each patient may use one gift certificate every 12 months; patients must present a gift certificate within the expiration date to receive charitable services. The date format printed on the gift certificates is in the YYYY.MM.DD format. For example, 2022.06.01 is June 1, 2022. Please check to make sure the certificate is being redeemed before the expiration date noted on the front and refer the patient back to the partner organization to obtain a new gift certificate if necessary. Unfortunately, VSP can’t accept claims on expired gift certificates, and the expiration dates cannot be extended.

Check Patient Eligibility

If patient has a Social Security number (SSN), check whether the patient has active coverage by using the “Member Search” button through eClaim on Eyefinity^® or by calling VSP customer service. Only the last four digits of the SSN are required. If no patient record appears, or if the patient does not have an SSN, proceed to the next step to validate the gift certificate. However, having an SSN is no longer a requirement for the individual to receive services or for the doctor to be compensated. Any discussion involving the SSN will be between the doctor and patient.

NOTE: 

A patient who does not have an SSN will not be a member in the VSP system.

• From the eInsurance tab, select the “Gift Certificate” button, enter the letters “GC” followed by the gift certificate number printed on the front (example: GC0000001), and click “GO.”
• Create the patient record using the pre-printed “Patient ID” number on the front.
• Once the patient record has been created, check benefits covered via the VSP Provider Reference Manual for Choice or the “Patient Record” tab in eInsurance.

NOTE: 

It may take 10-15 minutes after the authorization is created for the data to display.

A ‘Patient ID’ number is pre-printed on the gift certificates. This number is to be entered into the Patient ID field in eInsurance.

Electronic claims

Submit the claim as you would for any VSP plan.

Paper claims

Keep a copy of the certificate in your patient’s file. Call 800.615.1883 if you have questions about submitting a paper claim.

Exam only - Submit the original certificate to us with a completed CMS-1500 claim form.

Exam and materials for Disaster Relief and VSP Eyes of Hope gift certificates – Submit the original certificate, a completed CMS-1500 claim form, and a completed VSP Materials Invoice form to a VSP wholly-owned lab. Please follow all other normal lab processing procedures; reserve private lab use for emergencies only.

NOTE: 

Use Patient ID number in place of SSN on the CMS-1500 claim form. See instructions in ‘Get an Authorization Number’ section above.

VSP Eyes of Hope gift certificates, including Disaster Relief gift certificates, cover any Marchon^® or Altair^® frame brand less than or equal to a $57 wholesale or $150 retail allowance. Brands with fully covered frames include Marchon NYC and Lenton and Rusby. Extra $20 does not apply. 

While patients do receive a 20% discount on the overage when selecting a frame over the wholesale and retail allowance, the intent is to cover a frame in full whenever possible. 

To add Marchon and Altair frames to your dispensary covered by the program, please contact your Account Executive. The collections can be viewed at marchon.com and altaireyewear.com

Lens benefits are noted in the section below.

Because VSP Eyes of Hope gift certificate programs are designed to provide a comprehensive eye exam and prescription glasses at no cost to those in need, VSP strongly encourages all VSP network doctors not to collect sales tax from these patients for covered materials.

Save a copy of the gift certificate in your patient’s file.

The below information relates to each specific gift certificate type. Verify the coverage before providing services to ensure that you’ll be reimbursed.

Eye care services and prescription eyewear are not available if already covered through a private insurer and/or a government program such as Medicaid.

Children covered by the VSP Access Plan may qualify if they meet all other eligibility criteria. Need clarification? Call VSP.

Only one gift certificate can be redeemed in any 12-month period. Glasses that are lost, stolen, or broken within 12 months after a previous certificate is redeemed won’t be covered or replaced.

Commonspirit Health, Catholic Health Initiatives, & Dignity Health (AKA CSH, CHI) 

(excluding Sierra Nevada Memorial Hospital & St. Joseph’s Regional Health)

Members of CommonSpirit Health and related entities are covered under VSP’s Choice Plan effective 1/1/2024.

VSP providers will receive their Choice Plan assigned fees for all services, except exams. For exams, the client has the following client-specific provider reimbursement:

• $50 Exam

You will see the following message code for members of CommonSpirit Health while reconciling your Explanation of Payment (EOP):

• CS = Service reimbursed per Client-Specific Fee Schedule. Please refer to the Client Detail page in the PRM for additional information.

Patients are not to be balanced-billed the difference between your assigned Choice exam fee and the client-specific exam fee.

For assistance regarding your EOP and this custom exam reimbursement, contact VSP at 800.615.1883.

VSP Choice Plan^® Lens Enhancements Charts

September 1, 2024 VSP Choice Plan^® Lens Enhancements Chart

June 27, 2023 VSP Choice Plan^® Lens Enhancements Chart

CHOICE EXAM PLUS PLANS

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.

Choice Exam Plus Plan and Choice Exam Plus with Allowances Plan eye exam fees are made according to your Choice Network Fee Schedule.

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

Note: 

Avoid reduced reimbursements. Bill separately for refraction (92015). Your Choice Network Fee Schedule lists your refraction fee.

Choice Exam Plus and Choice Exam Plus with Allowances patients are entitled to savings on glasses and contact lens services. Choice Exam Plus with Allowances patients are eligible for additional materials benefits based on a client-determined schedule of allowances. Refer to VSP Exam Plus and Exam Plus with Allowances in the VSP Manual for more information.

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

Exam Plus Savings Plan^™

Exam Plus Savings Plan is a new Choice product that offers patients a covered exam, less any copay, and a competitive national lens fee schedule, special pricing on lens enhancements, and savings* on frames and contact lens exams.

Obtain eligibility on eyefinity.com or by calling VSP at 800.615.1883.

Exam Plus Savings Plan is listed on the VSP Patient Record Report under Benefit.

Note: 

Coordination of benefits is allowed; refer to the Choice Secondary Allowance for exam only.

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.

• Eye exam fees are made according to your Choice Network Fee Schedule, less applicable copay.
• Deduct 20% 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: patients pay $39 or your U&C fee, whichever is lower.

Use the following to charge eligible patients for frames, lenses, and lens enhancements when a complete pair of prescription glasses is dispensed.

• Eligible patients can receive unlimited complete sets of prescription glasses from any VSP doctor.
• Is unlimited for 12 months on or following the date of the last covered eye exam.
• Patient is not required to receive exam from your office to receive material savings
• Use professional judgment when evaluating prescriptions from another doctor. If necessary, you can request an additional routine exam at 80% of U&C.

Frame: patients pay 75% of the retail price of the frame.

Lens enhancements: use the Choice Plan Lens Enhancements Chart to determine patient pricing for lens enhancements.

Be aware of the following materials requirements:

Note: 

Claims that don’t meet these requirements will be denied.

• Must provide complete pairs of glasses with both lenses and frame
• Only complete sets of lenses (includes balance lenses)
• Proprietary lens and frame are not allowed
• Frame must be doctor-supplied (not lab or patient-supplied)
• In-office finishing or the use of a non-VSP Network Lab is not allowed.
• 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).

Non-prescription glasses or sunglasses: charge 80% of U&C for complete pairs of non-prescription glasses or sunglasses and blue light filtering glasses dispensed within 12 months of the exam.

Charge eligible patients 85% of U&C for contact lens exam services (F&E) and follow-up services, and 100% of U&C for contact lens materials.

• Applies to services for prescription contact lenses only.
• Is unlimited for 12 months on or following the date of the last eye exam.
• Is available through any VSP doctor. Use professional judgment when evaluating prescriptions from another doctor.
• Discount doesn’t apply to contact lens materials, solutions, cleaning products, or service agreements.

The benefits are considered a private transaction between you and your patient; your patient is responsible for paying for the services or materials.

Note: 

Handle contact lens services and materials as a private transaction, no claim submission required. If submitted, contact lens services will be denied.

Orders must be sent to a VSP Network Lab. Use of a private lab or in-office finishing is not allowed and will cause the claim to deny.

Patients are eligible for the Laser VisionCare Program. Refer to the VSP Laser VisionCare Program page in the VSP Manual.

See the Laser VisionCare Program section under Programs on VSPOnline at eyefinity.com for information on how to participate or for a list of participating facilities.

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

Professional Services

Eye exam: you’ll be reimbursed by VSP according to your Choice Network fees.

Contact lens exam (fitting and evaluation): patient pays you directly at 85% U&C.

Retinal screening: patient pays you directly, up to $39.

Materials

Note: 

The patient pays the material fees to your office directly. Just like any other VSP Choice Plan, VSP pays the lab on your behalf—so the "VSP Pays Doctor" column on your EOP will show a negative amount.

Base lenses: you'll be reimbursed according to your Choice Network fees.

Lens enhancements: your service fees and chargebacks will be calculated as usual based on the VSP Choice Plan Lens Enhancement chart to cover material costs.

Contact lenses: patient pays 100% of U&C directly to you.

Non-prescription glasses or sunglasses: patient pays 80% of U&C directly to you.

Frame: Your frame compensation is calculated using the wholesale frame allowance (up to $57), plus your Choice Plan frame dispensing fee, plus 80% of the retail price over $150, which is the same as your Choice fees.

Example: Patient chooses a frame with a retail price of $200 and wholesale cost of $76.

VSP Choice compensation allowed amount:

The difference between what the patient pays and the total compensation amount is a chargeback (-$34).

The chargeback is collected from the patient’s payment to cover administrative costs of the program.

*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.

VSP Choice Access^® Plan

The VSP Choice Access Plan is a savings plan with regional pricing on exams, lenses, and certain lens enhancements (listed below) that provides a savings to eligible patients when they see a VSP Choice Network Doctor. Benefits may be used an unlimited number of times during the patient's enrollment in the VSP Choice Access Plan.

The plan is not available in Montana, Vermont, Washington, Guam, Puerto Rico, and the U.S. Virgin Islands.

• Verify eligibility through eyefinity.com or call VSP at 800.615.1883.
• You can view the Patient’s Record Report for plan information including savings information and regional pricing.

Important! 

There are no authorizations or claims to file—just bill the patient directly after applying the appropriate fees.

Provide the level of exam needed to determine your patient’s visual health status. Use professional judgment when evaluating prescriptions from another doctor. You may request an additional exam at 80% of U&C.

• Savings only applies to services and procedures included in a WellVision Exam^®. It doesn’t apply to additional diagnoses and treatment.
• Deduct 20% from your U&C fees for a WellVision Exam and then compare the fee to the pricing for your region--charge the patient the lower of the two.

Eligible patients get the following discounts on glasses, sunglasses, and lens enhancements for prescription and non-prescription lenses:

Lens

• Charge 80% of U&C fees for base lenses up to the regional member fee.

Lens Enhancements

• Polycarbonate: Charge 80% of U&C fees or $40, whichever is less.
• Standard Anti-Reflective Coating (Code QM Only): Charge 80% of U&C fees or $45, whichever is less.
• All other Anti-Reflective Coatings (refer to the Product Index): Charge 80% of U&C fees.
• Standard Scratch Coating (Factory Applied Only): Charge 80% of U&C fees or $15, whichever is less.
• UV Coating: Charge 80% of U&C fees or $15, whichever is less.
• Standard Progressive (Code KA): Charge 80% of U&C fees or $55, whichever is less (only the amount over the base lens – flat top 28).
• Premium and Custom Progressive (Code FA, JA, NA, OA): Charge 80% of the additional U&C cost for the progressive (only the amount over the base lens—flat top 28).
• Higher Powers: Charge 80% of the additional U&C cost for high powers lenses.
• All Other Lens Enhancements & Features: Charge 80% of U&C fees.

For progressives, subtract the U&C FT28 bifocal cost from the progressive U&C fee, and then deduct 20% off that amount.

You can use this example to help determine what to bill a patient for a progressive lens. In this example, the practice is located in Arkansas (or Region 4).

*Important! 

Please refer to the Lenses section above to determine the appropriate bifocal price for your region based on your office location.

Frame

• Charge 75% of U&C.
• Savings don’t apply if the frame manufacturer prohibits discounts.

Contact Lenses

• Charge 85% of U&C fees for contact lens services (fitting and evaluation) for prescription lenses only.
• Charge 100% of your U&C fees for contact lens materials, solutions, or cleaning products.

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

Refer to the Laser VisionCare section of the VSP Manual for information.

Important! 

There are no claims to file.

Apply the corresponding savings to your U&C fees, with the not-to-exceed maximums. Collect the appropriate fees from the patient. Handle the transaction as a private payment arrangement.

The applicable regional prices are listed on the Patient Record Report and are also included below for your reference.

Charge patients 80% of your U&C fees or price for your region—whichever is lower.

VSP^® Vision Savings Pass^™

VSP Vision Savings Pass is a non-insurance product that offers patients clear, straightforward pricing for an exam and glasses. It provides a competitive national fee schedule, special pricing on lens enhancements, and savings* on frames and contact lens exams.

Obtain eligibility on eyefinity.com or by calling VSP at 800.615.1883.

VSP Vision Savings Pass is listed on the VSP Patient Record Report under Benefit.

Note: 

Coordination of benefits is not allowed because this is a non-insurance product.

Patients are eligible for an annual eye exam. Charge $50 for the exam with the purchase of complete pairs (lenses and frame)* of prescription glasses (bill the exam with glasses, on the same claim, to ensure accurate claim processing). Patients who select contacts or who don’t purchase prescription glasses pay 80% of your U&C fee for the exam.

• Savings only applies to services and procedures included in a WellVision Exam^®. It doesn’t apply to additional diagnoses and treatment.
• Use professional judgment when evaluating prescriptions from another doctor. You can request an additional routine exam at 80% of U&C.
• Retinal screening: patients pay $39 or your U&C fee, whichever is lower.

See Client Exceptions below.

Use the following to charge eligible patients for frames, lenses, and lens enhancements when a complete pair of prescription glasses is dispensed. Eligible patients can receive unlimited complete sets of prescription glasses or plano (non-prescription) sunglasses from any VSP doctor.

Note: 

Patient is not required to receive exam from your office to receive savings. Use professional judgment when evaluating prescriptions from another doctor.

Frame: patients pay 75% of the retail price of the frame.

Lens enhancements: use the Choice Plan Lens Enhancements Chart to determine patient pricing for lens enhancements.

Non-prescription glasses or sunglasses: charge 80% of U&C for complete pairs of non-prescription glasses or sunglasses dispensed within 12 months of the exam.

Be aware of the following materials requirements:

Note: 

Claims that don’t meet these requirements will be denied.

• Must provide complete pairs of glasses with both lenses and frame
• Only complete sets of lenses (includes balance lenses)
• Proprietary lens and frame are not allowed
• Frame must be doctor-supplied (not lab or patient-supplied)
• In-office finishing or the use of a non-VSP Choice Network Lab is not allowed.

Charge eligible patients 85% of U&C for contact lens exam services (F&E) and follow-up services, and 100% of U&C for contact lens materials.

• Applies to services for prescription contact lenses only.
• Is unlimited for 12 months on or following the date of the last eye exam.
• Is available through any VSP doctor. Use professional judgment when evaluating prescriptions from another doctor.
• Discount doesn’t apply to contact lens materials, solutions, cleaning products, or service agreements.

These benefits are considered a private transaction between you and your patient; your patient is responsible for paying for the services or materials.

Note: 

Unless otherwise indicated on Patient Record Report, handle contact lens services and materials as a private transaction, no claim submission required. If submitted, contact lens services will be denied.

Patients are eligible for the Laser VisionCare Program. Refer to the VSP Laser VisionCare Program page in the VSP Manual.

See the Laser VisionCare Program section under Programs on VSPOnline at eyefinity.com for information on how to participate or for a list of participating facilities.

Orders must be sent to a VSP Choice Network Lab. Use of a private lab or in-office finishing is not allowed and will cause the claim to deny.

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

Note: 

Be sure to bill the exam with glasses on the same claim for accurate claim processing. Don’t split the billing.

Note: 

The patient pays the majority of the fees to your office directly. Just like any other VSP Choice Plan, VSP pays the lab on your behalf—so the “VSP Pays Doctor” column on your EOP will show a negative amount.

Eye exam: When billed with prescription glasses, you’ll be reimbursed by VSP according to your Choice Network fees. Without prescription glasses, patient pays you directly at 80% U&C.

Contact lens exam (fitting and evaluation): patient pays you directly at 85% U&C.

Retinal screening: patient pays you directly, up to $39.

Base lenses: you’ll be reimbursed according to your Choice Network fees.

Lens enhancements: your service fees and chargebacks will be calculated as usual based on the VSP Choice Plan Lens Enhancement chart to cover material costs.

Contact lenses: patient pays 100% of U&C directly to you.

Non-prescription sunglasses: patient pays 80% of U&C directly to you for complete pairs of non-prescription sunglasses and blue light filtering glasses dispensed within 12 months of the exam.

Frame: Your frame compensation is calculated using the wholesale frame allowance (up to $57), plus your Choice Plan frame dispensing fee, plus 80% of the retail price over $150, which is the same as your Choice fees.

Example: Patient chooses a frame with a retail price of $200 and wholesale cost of $76.

The difference between what the patient pays and the total compensation amount is a chargeback (-$34).

The chargeback is collected from the patient’s payment to cover administrative costs of the program.

Members of the following clients pay a flat $50 exam fee, regardless of glasses purchase:

• Vermont Health Plan (only applies to some pediatric members)

Refer to the member’s Patient Record Report to verify patient pay amount.

*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.