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 .

2 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.

3 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.

4 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. Provider Reference Guide | Table of contents 4 MARCH PRG_02222022 PCA-1-21-02865-MarComm_BROC_10027021 Section 1: General information Contact information.

5 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.

6 13 Billing for glaucoma screenings .. 14 Telemedicine .. 14 Frame warranty .. 14 Guidelines for patient supplied frames .. 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.

7 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 .. 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.

8 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.

9 35 Face-to-face and American Sign Language interpreting services .. 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)

10 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) 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.