MARCH Vision Care Provider Reference Guide

1 1 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 Jennjennygoogle Provider Reference Guide | Disclaimer and Notice of Updates 2 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 Disclaimer: This document is for the use of providers participating with MARCH Vision Care, Incorporated; MARCH Vision Care IPA, Incorporated; or MARCH Vision Care Group, Incorporated (each, as applicable, MARCH ). No part of this Guide may be reproduced or transmitted in any form, by any means, without prior written consent from MARCH . Contents copyright, 2010-2022, by MARCH . Subject to applicable law, MARCH reserves the right to change this Guide at its discretion. Provider Reference Guide Notice of Updates effective April 2022: Section 1: General information Removed Mailing address Updated address Section 3: Billing and claim procedures , , , Updated address Provider Reference Guide | About the Provider Reference Guide 3 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 About the Provider Reference Guide MARCH Vision Care is committed to working with you and your staff to achieve the best possible health outcomes for our members.

2 This Guide provides helpful information about eligibility, benefits, claim submission, claim payments, and much more. For easy navigation through this Guide , click on the Table of Contents to be taken to the section of your choice. This version of the Provider Reference Guide ( PRG ) was revised in February 2022. Reviews and updates to this Guide are conducte d as necessary and appropriate. Update notifications are distributed as they occur through Provider newsletters. Recent newsletters and a current version of this Guide are on To request a current copy of the PRG on CD, please visit our Contact Us webpage at > Provider resources>Contact us for your state-specific Provider Relations phone number. Terms used in this manual include the following: You , your , or Provider refers to any Provider subject to this PRG (with the exception the verbiage in Section 6: Members Rights and Responsibilities you and your refer to the member) Us , we , our , MARCH refers to MARCH Vision Care for those products and services subject to this PRG Thank you fo r your participation in the delivery of quality Vision care services to our members.

3 Provider Reference Guide | Table of contents 4 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 Section 1: General information Contact information .. 6 .. 6 Registration .. 6 Sign in .. 6 Interactive Voice Recognition (IVR) System .. 7 Registration .. 7 Sign in .. 7 Electronic funds transfer (EFT) .. 7 Provider change notification .. 8 Section 2: Eligibility and benefits Eligibility and benefit verification .. 9 Confirmation numbers .. 9 Covered benefits .. 9 Methods of verification .. 9 Non-covered services .. 10 Section 3: Billing and claim procedures Claim submission .. 11 Preferred method .. 11 Clearinghouse submissions .. 11 Paper claims .. 11 American Medical Association CPT coding rules .. 12 Billing for replacements and repairs .. 13 Billing for glaucoma screenings .. 14 Telemedicine .. 14 Frame warranty .. 14 Guidelines for patient supplied frames.

4 14 Order cancellations .. 14 Non-covered lens opti ons .. 15 Billing of Medicare allowance .. 15 Frames and lenses .. 15 Contact lenses .. 15 Claim fili ng limits .. 16 Proof of timely filing .. 16 Prompt claim processing .. 17 Corrected claims .. 18 Provider disputes .. 19 Provider dispute types .. 19 Provider dis pute resolution process .. 19 Overpayment of cla ims .. 21 Balance billi ng .. 21 Coordinatio n of benefits .. 21 Section 4: Standards of accessibility Access standards .. 23 Access monitoring .. 23 Section 5: Member grievances and appeals Protocol for member grievances/appeals .. 25 Definitions .. 25 Potential quality issue .. 25 Section 6: Member's rights and responsibilitie s Member rights .. 26 Member responsibilitie s .. 26 Section 7: Health care services Qualit y Management Program .. 27 Coordination with Primary Care Providers.

5 27 Clinical decision making .. 27 Medical charting for eye care servic es .. 27 Paper charts .. 27 Electronic Medical Records .. 28 Critical elements of an eye exam .. 28 Section 8: Fraud, Waste, and Abuse Anti -Fr aud Plan .. 30 Training of providers concerning th e detection of health care fraud .. 30 Sanction list monitoring .. 31 Document retention .. 31 Reporting Suspected Fraud, Waste, o r Abuse (FWA) .. 30 Section 9: Credentialing Credentialing and re-credentialing .. 32 CAQH .. 32 Credentialing process .. 32 Re-credentialing process .. 32 Health plan credentialing process .. 32 National Provider Identifier .. 33 Disclosure of Criminal Conviction, Ownership and Control 33 Section 10: Language Assistance Program Senate Bill 853 Language Assistance Program (LAP) .. 34 Access to interpreters .. 34 Telephonic interpreting services .. 35 Face-to-face and American Sign Language interpreting services.

6 35 Medical record documentation for LAP .. 35 Documentation of Provider /Staff Language Capabilities .. 36 Translation of writt en material .. 36 Additional Language Assistance Program inf ormation for providers .. 36 Section 11: Cultural competency Cultural competency .. 37 Section 12: Secure transmission of Protected Health Information Secure transmission of Protected Health Inf ormation (PHI) .. 38 Provider Reference Guide | Table of contents 5 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 Exhibits Exhibit A Non-Covered Service Fee Acceptance form Exhibit B Provider Dispute Resolution Request form (online) Provider Dispute Resolution Request form (paper) Exhibit C Prison Industry Authority (PIA) Optical Lab information Exhibit D Lab Order form Exhibit E Tips for documenting interpretive se rvices for limited English proficient members Notating the Provision or the Refusal of Interpretive Services Exhibit F Member Grievance form for California members only (English and Spanish)

7 Exhibit G Potential Quality Issue Severity Levels Exhibit H Potential Quality Issue Referral form Exhibit I Clinical Practice guidelines Exhibit J Wholesale/Retail fee schedule Exhibit K Health Care Provider application to Appeal a Claims Determination (HCAPAA) Exhibit L Sending a secure email to MARCH Vision Care for PHI rel ated data Exhibit M Examination Record template Exhibit N Disclosure of Ownership and Control Interest Statement Exhibit O HEDIS/Stars Performance Reporting *All forms and documents linked above can also be found on Provider Reference Guide | Section 1: General information 6 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 Contact information General website Provider website Lab and Contact Lens orders Please visit our Contact Us webpage at > Provider resources>Contact us for your state-specific Provider Relations phone number.

8 We are proud to offer our web-based solution fo r electronic transactions. On , you can: Verify member eligibility and benefit status Obtain co-payment and remaining allowance information Submit and track claims and lab orders electronically to reduce paperwork and eliminate costs Create new accounts and grant access to multiple users with user administration capabilities Generate confirmation numbers for services (for the definition of confirmation number , refer to section ) Obtain detailed claim stat us including check number and paid date Access online resources such as current PRGs, state -specific benefits, and the User Guide . IMPORTANT: If you choose not to submit lab orders through , you must fax your order to our Customer Service Center at (855) 640-6737. Registration First-time users must register before accessing Please be prepared to enter your tax identification number, office phone number, and Registration number*.

9 Once verified, you will complete the registr ation process, which includes creating a username and password. The first person registering for the account will be assigned the Account Administrator role . *Contact the Provider Relations department to access your unique Registration number Sign in Once registered, you may sign in at wi th your username and password. Remember that passwords are case-sensitive. As a security feature, you will be asked to renew your password every 60 days. You can reset your own expiri ng password by selecting the change your password link in the message banner on the home page If the password has already expired, will automatically redirect you to t he password reset page upon login You can also retrieve a forgotten password, b y selecting the Forgot your Password? link on the sign-in page As an additional safety feature, you are required to eit her call or contact your Account Administrator to have your password reset after 5 failed log-in attempts.

10 Once lo gged in , you may access the User Guide located on the Resources menu. This Guide includes step-by-step instructions for completing various transactions within Interactive Voice Recognition System Our Interactive Voice Recognition (IVR) System provides responses to the fo llo wing inquiries 24 hours per day, 7 Provider Reference Guide | Section 1: General information 7 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 days a week: Eli gibility and benefits Confirmati on numbers Cl aim status You may access the IVR System by calling the appropriate state-specific phone number found on our Contact Us webpage ( > Provider resources>Contact us). Select the Provider option and follow the prompts to verify eligibility and benefits, request a confirmation number, or check claim status. Registration First-time users must register before accessing the IVR System.