Professional Provider Manual

1 Professional Provider Manual Revised November 2023. Requirements Table of Contents Just click the page number link to go directly to the section you need. Introduction .. 5. Requirements .. 6. Participation requirements and responsibilities .. 7. Claims and payments Credentialing and recredentialing .. 8. Fill-in doctors .. 11. Access to care/emergencies .. 12. Member con dentiality and privacy laws .. 14. Cultural competency and language assistance .. 14. Medicare and Medicaid participation .. 15. Plan benefits State laws .. 16. Mobile providers .. 17. Network terminations .. 18. Payments .. 20. Chargebacks and lens payments when using the lab network.

2 21. Payments for medically necessary contact lenses .. 21. Payments for special services .. 22. Government Client-speci c payments .. 23. programs Services and materials .. 24. Eye exam services .. 25. Pediatric Vision Bene ts .. 28. Contact lens t and follow-up and materials .. 30. Lenses .. 32. quality assurance Compliance and Frames .. 34. Plano lenses and frame-only transactions .. 36. Eyewear warranties and return policies .. 37. Discounts .. 37. Medically necessary contact lenses .. 38. Diabetic Eye Care plans .. 42. Safety Eyewear Program powered by EyeMed .. 43. and operations Lab processes Low vision bene ts.

3 48. Utilization Management (Medical/Surgical Eye Care) .. 51. Limitations and exclusions .. 53. Claims .. 55. Members with medical and vision bene ts .. 56. Coordination of bene ts .. 57. Submitting claims .. 58. Client-specific requirements Voiding and correcting claims .. 63. November 2023 2. Proprietary and Confidential - For use by EyeMed network providers only TRADE SECRETS. Requirements Claim payments and withholds .. 64. Claim denials .. 66. Compliance and quality assurance .. 68. Assisting a member with an appeal .. 69. Utilization Management appeals .. 69. De nitions .. 69. Provider post-service claim appeals process.

4 69. Claims and payments Returning to the network after involuntary termination .. 70. Medicaid appeals .. 72. Colorado appeals .. 72. California disputes and appeals .. 72. Fraud, waste and abuse prevention .. 74. Delaware appeals .. 75. Plan benefits Provider audits .. 75. Annual training requirements .. 77. Lab processes and operations .. 79. Lab network .. 80. Product catalog requirements .. 81. Sales and use tax .. 82. Emergency eyewear orders .. 83. Government Lens Only Program .. 84. programs Lab order refunds, returns and remakes .. 85. Uncut lens program .. 87. Single Vision In-O ce Finishing Program.

5 88. Client-speci c requirements .. 91. Client-speci c plan rules .. 92. quality assurance Compliance and Medicaid plan-speci c requirements .. 122. Provider Manual glossary .. 135. Provider Manual glossary .. 136. and operations Lab processes Client-specific requirements November 2023 3. Proprietary and Confidential - For use by EyeMed network providers only TRADE SECRETS. Claims and Government Compliance and Lab processes Client-specific Requirements Plan benefits payments programs quality assurance and operations requirements TRADE SECRETS. 4. Proprietary and Confidential - For use by EyeMed network providers only November 2023.

6 Requirements Introduction . This version of the EyeMed Vision Care Professional Provider Manual supersedes any prior Manual you have received from EyeMed. EyeMed reserves the right to revise these policies and procedures at our sole discretion and at any time. All applicable laws and regulations supersede the provisions of this Manual . This Provider Manual is con dential and should not be shared with third parties. Claims and payments E ective Date: July 1, 2023. Plan benefits You can view the July 1, 2023 December 30, 2023 Provider Manual here. You can view the e ective December 31, 2023 Provider Manual here.

7 Government programs quality assurance Compliance and and operations Lab processes Client-specific requirements November 2023 5. Proprietary and Confidential - For use by EyeMed network providers only TRADE SECRETS. Requirements Requirements What are your requirements to be an eyemed Provider ? November 2023 6. Proprietary and Confidential - For use by EyeMed network providers only TRADE SECRETS. Requirements Participation requirements and responsibilities Minimum participation requirements TPA and DEA certi cation/licensing. You need to have either a TPA certi cate or DEA license, except in Puerto Rico. You can use diagnostic pharmaceutical agents (DPAs) as long as the member's age, condition type and severity and other contributing factors justify it.

8 Use therapeutic pharmaceutical agents (TPAs) as appropriate when a member has a condition that requires them, but get the member's consent. You can also refer them to another health care Professional as stated in their medical care plan. As with DPAs, document member refusals or referrals. Good standing. To be eligible for participation on our networks, you have to be in good standing with EssilorLuxottica and all relevant subsidiaries. This includes being current with all nancial obligations and complying with all contractual commitments and policies. Professional liability insurance. Contracted eye care professionals and all a liated eye care professionals must maintain Professional liability insurance in the amount of $1,000,000 per occurrence and $3,000,000 aggregate.

9 In states that have limitations on liability, state law applies. An umbrella policy can meet these requirements. Commercial liability insurance. You must maintain commercial liability insurance in the amount of $1,000,000 per occurrence and $2,000,000 in aggregate. Your responsibilities Full-service locations. All participating Provider locations must o er both exams and materials. Open to new patients. All locations must accept new patients. Member eligibility and access. You can't turn away members and must represent yourself as an in-network Provider to them. You can't submit claims for out-of-network services on behalf of members if you participate in their network(s).

10 November 2023 7. Proprietary and Confidential - For use by EyeMed network providers only TRADE SECRETS. Requirements Claims. Submit all required claims information . Disparagement. Do not share your concerns/issues about EyeMed publicly. Instead, follow the Provider complaints and appeals processes. information veri cation. When EyeMed asks you to report or verify information through our Provider website, inFocus, you must report the information timely, accurately and completely. You may be asked to supply signed con rmation. Network participation Additional networks. You may be contracted for speci c networks only.