Vision Care Affiliate Provider Reference Manual Effective ...

1 VSP Vision care Affiliate Provider Reference Manual Questions? or 1 VSP Vision care Affiliate Provider Reference Manual Effective october 1, 2016 Version october 1, 2016 VSP Vision care Affiliate Provider Reference Manual Questions? or 2 Note: This Manual remains the sole and exclusive property of VSP. The information contained in this Manual is confidential and proprietary, and the Affiliate Provider is granted a limited personal and nontransferable license for use of the content of this Manual during participation on the VSP network. The contents of this Manual may not be used, copied, and/or reproduced for any other purpose, or disclosed and/or disseminated to any third party for any purpose whatsoever, without the prior written consent of VSP. If, for any reason, the Manual recipient no longer participates on the VSP network, the recipient hereby agrees, and is directed, to immediately destroy this Manual , all copies, and any and all amendments and addenda that may be issued by VSP from time to time.

2 VSP Vision care Affiliate Provider Reference Manual Questions? or 3 TABLE OF CONTENTS TABLE OF CONTENTS .. 3 SET UP AN ACCOUNT ON .. 4 CHECK FOR PATIENT ELIGIBILITY .. 6 IDENTIFY THE PATIENT S COVERAGE .. 7 DETERMINE WHAT TO CHARGE THE PATIENT .. 8 SUBMIT THE CLAIM .. 11 BILLING CODES .. 18 CLAIM INQUIRIES .. 24 CLIENT DETAILS: METLIFE Vision .. 26 COMPLAINTS AND GRIEVANCES .. 27 INSURANCE, LICENSURE AND CERTIFICATION .. 31 OFFICE STANDARDS ..32 PATIENTS RIGHTS AND RESPONSIBILITIES .. 36 CLAIM APPEALS ..39 SERVICES SUBJECT TO REVIEW/AUDIT .. 41 QUALITY ASSURANCE PROGRAM ..43 QUALITY MANAGEMENT PROGRAM ..46 VSP S FRAUD AND ABUSE POLICY ..48 Provider DISPUTE RESOLUTION THIS Affiliate Provider REFERECE Manual IS FOR USE BY RETAIL Vision CENTERS AND Affiliate PROVIDERS WHO ARE LEGALLY ASSOCIATED WITH A COMPANY (AS EMPLOYEES, INDEPENDENT CONTRACTORS OR CONTRACTED ARRANGEMENTS) THAT HAS ENTERED INTO A NETWORK Affiliate AGREEMENT WITH VSP.

3 SO LONG AS THE Affiliate AGREEMENT REMAINS IN EFFECT, THE PROVIDERS AND RETAIL Vision CENTERS LEGALLY ASSOCIATED WITH THE COMPANY ARE GRANTED Affiliate STATUS TO PARTICIPATE ON THE VSP Provider NETWORK, AS OUTLINED IN THE NETWORK Affiliate AGREEMENT, APPLICABLE NETWORK PARTICIPATION AGREEMENTS AND IN THIS Manual . RETAIL Vision CENTERS AND Affiliate PROVIDERS CAN CHECK MEMBER ELIGIBILITY, PROVIDE EXAMS AND MATERIALS, AND SUBMIT CLAIMS FOR CERTAIN VSP MEMBERS AND DEPENDENTS. THEY ARE ALSO INCLUDED IN THE FIND A DOCTOR LISTING ON FOR CERTAIN VSP MEMBERS. Please remember that this program is limited and comes with some restrictions. You aren t a full in-network VSP Provider and can t promote yourself as one under thesearrangements. You may not advertise or use any name, symbol, or trademark of VSP in any advertisingexcept as otherwise approved by VSP in writing. To the extent use is permitted, you agree touse VSP s names, logos, trademarks and service marks only in accordance with a separatelimited license agreement granted to you by VSP.

4 All providers who provide services to a VSP patient in the practice must Vision care Affiliate Provider Reference Manual Questions? or 4 SET UP AN ACCOUNT ON is a secure, HIPAA-compliant site that enables you to verify eligibility and submit claims for VSP members. To set up an account: your web browser and go to ; click Sign up for an and accept the Privacy Policy and Terms and your email the appropriate account type from the dropdown: Retail Chain Full Service Location (your location provides exams, glasses, andcontacts) Retail Chain Dispensary Only (your location provides glasses and contacts only--noexams) Retail Chain Independent Doctor (your location provides exams and may dispensecontacts) Submit. You ll receive an email with a verification code to complete your the link in the email to be connected to the confirmation a password and enter it in New Password and Confirm New Password. Click Verifyto proceed to the Welcome and note your account information you ll need it for future Profile to go to the Account Profile page.

5 You may see an alert message thisappears when the Account Profile information is Vision care Affiliate Provider Reference Manual Questions? or 5 of the Account profile information will be pre-populated. Complete any open fields andclick Save : Enter the office phone number in the Billing Provider Information section. Using the billing location s phone number here will cause an error that prevents you from proceeding. Federal Tax ID: the SSN or Employer Identification Number of the doctor receiving VSP payment. NPI: the 10-digit, Type 1 universal ID number of the billing Provider . VSP Vision care Affiliate Provider Reference Manual Questions? or 6 CHECK FOR PATIENT ELIGIBILITY Before providing services, make sure the patient is eligible for benefits. You can do this on or by phone. The eligibility document, called the VSP Patient Eligibility Report, shows you the patient s eligibility for services, copays, and coverage. Check eligibility on in to and click Eligibility Check.

6 Complete all fields and click you re checking eligibility for a dependent, you ll need their first name, last name, and dateof birth in addition to the member s information shown VSP Patient Eligibility Report will appear in a new : If you can t see the report, it could be because your web browser blocks pop-ups. If this is the case, you ll see a yellow bar at the top of your screen. Move your cursor over the bar, right click, and select "always allow pop-ups from this site." Another box will appear to verify the change click yes and the report will open in a new window. the report you ll need the Authorization Number to file the eligibility by phone VSP at to access the automated your office s phone number and the following information: Member ID or last four digits of the member s SSN Member first and last name; patient first and last name and date of ll receive an Authorization Number to enter into or Insured ID: the last four digits of the member s SSN, or full ID number assigned by the client.

7 Insured: the VSP member. VSP Vision care Affiliate Provider Reference Manual Questions? or 7 IDENTIFY THE PATIENT S COVERAGE Use the VSP Patient Eligibility Report to determine the patient s coverage. VSP Coverage The Patient Identification section shows VSP Eligibility and the Authorization Number. Out of Network Coverage The Patient Identification section shows Out of Network Eligibility and the Authorization Number. If the patient has Out-of-Network coverage, exam and materials are covered up to the amount(s) listed. You may charge the patient for any amount over what s listed. Neither VSP nor Out of Network Coverage If the patient doesn t have VSP coverage or Out-of-Network coverage, the Eligibility Check screen will show the following alert message: Your eligibility check for [PATIENT] was successful. However, he or she is unable to use their VSP benefits at your location. Please handle as a private transaction. VSP Vision care Affiliate Provider Reference Manual Questions?

8 Or 8 DETERMINE WHAT TO CHARGE THE PATIENT The VSP Patient Eligibility Report shows what to charge the patient for the eye exam and materials. Important! You re not required to honor your organization s coupons or sale prices for VSP members using their benefit. If a VSP patient wants to use your organization s coupon or sale pricing, they can submit their claim to VSP as Out of Network. Exam The Patient Coverage section shows the patient s eligibility as well as the benefit type and client name. Eligible patients may choose either spectacles or contact lenses but are not eligible for both. If the patient is covered for Retinal Screening, it will be listed here with the applicable copay amount. Retinal screening is offered to VSP clients for purchase as an optional benefit enhancement. This benefit is for routine, retinal, or fundus photography or imaging such as Optos, but not scanning laser procedures such as OCT, HRT, or GDX. VSP considers fundus photography and optomap retinal exams to be separate procedures.

9 They are not acceptable as a replacement for performing direct or indirect ophthalmoscopy, and they do not replace dilation for patients with diabetes or other conditions requiring dilation based on standard of care . NOTE: Retinal screening claims must be submitted with an exam claim and must use CPT code 92250 with modifier 52. Patients with Diabetes The American Diabetes Association, American Optometric Association, and American Academy of Ophthalmology recommend that patients with diabetes receive an annual dilated eye exam. This exam is also a measure of clinical quality designated by the National Committee for Quality Assurance (NCQA). We require that eye exams for VSP patients with diabetes include dilation. We recognize that at times there are good reasons for not providing a dilated exam. In those cases, documentation of the rationale for not performing dilation is required. Examples include: Patient refused. Dilated exam was performed within the last 12 months.

10 Patient is under the care of an Vision care Affiliate Provider Reference Manual Questions? or 9 Patient scheduled dilation for a later Details The Plan Details secti on outlines the patient copays, allowances, and the value added benefits. FramePatients who select a frame that exceed their Wholesale Frame Allowance (WFA) and their Retail Frame allowance should receive a 20% savings on the overage. However, patients selecting a frame with either a wholesale cost less than their wholesale allowance (WFA) or a retail cost less than their retail allowance do not owe any frame overage. Note: Modifier KX must be included with the frame code (V2020 or V2025) when billing for Marchon or Altair frames to receive the increased reimbursement. Most VSP members (not out-of-network patients) will have an extra $40 on top of their frame allowance to spend on Calvin Klein1 and Cole Haan frames between November 16, 2016 and March 31, 2017. Reimbursement is based on the higher frame allowance.