To dispute/appeal a claim based on an individual claim denial, a bundle of claims denial or dissatisfaction with a claim payment, you may appeal by filing a claim dispute or appeal. See Appeal Process below.

For other disputes, including disputes related to Network Doctor Adverse Actions and actions as a result of an audit conducted pursuant to VSP’s Fraud, Waste and Abuse Policy, please see VSP’s Dispute Resolution Policy under the Policies section of this manual. The Fraud, Waste and Abuse Policy can be found under this same section.

To check the status of a claim, call VSP at 800.615.1883 or access eyefinity.com.

For claim corrections, such as a diagnosis code, billed amount or service code, call VSP at 800.615.1883 or complete the claim correction form on eyefinity.com.

VSP considers you to be authorized to act on behalf of your patient in pursuing appeals of denied claims. It’s your responsibility to:

• Inform patients of their right to appeal a claim denial.
•  Explain the appeal process to your patients.
• Get your patients’ approval to act as their authorized representative in the appeal process. If your patients don’t agree to you representing them in the appeal process, please direct them to contact VSP Member Services at 800.877.7195.

This Appeal process is for disputes/appeals related to individual claim denials, a bundle of claims denial or your dissatisfaction with a claim payment. All other disputes shall be submitted pursuant to VSP’s Dispute Resolution Policy cited above.

All Appeals under this section can be submitted online, by mail, or by phone. Incomplete appeals will be returned.

A sample Provider Claim Dispute Request Form is provided in the Tools & Forms section of this manual. If you prefer to submit a written appeal without using the form, please include the following information with your written appeal:

1. Your name and Payment Arrangement ID number
2. Your contact information
3. Original claim number (listed on the Explanation of Payment)
4. Supporting documentation

You can appeal multiple “like” denials (i.e., numerous claims denied for untimely filing) at the same time by using the Multiple-Provider Claim Dispute Form with the Provider Claim Dispute Request.

For most states and plans, appeals must be submitted to us within 180 calendar days from the date of the Explanation of Payment. See state and plan exceptions for specific timeframes and rules.

• Online: Complete the Provider Claim Dispute Request Form available in the Forms Library under Administration on VSPOnline on eyefinity.com.
• Mail: Send appeals to: VSP Claim Appeals, PO Box 2350, Rancho Cordova, CA 95741-2350.
• Phone: Call VSP at 800.615.1883

We’ll review your appeal and send a written response within 30 calendar days for most states and plans. Should the initial denial be upheld, you have the right to pursue a second-level appeal. Second-level appeals must be received within 60 calendar days from the date of the letter stating that the appeal has been denied. Follow the same process listed above to submit second-level appeals.

Arizona

Arizona Medicaid has unique requirements. For more information, see Submitting Claims/Billing, Reimbursement, & Appeals section in the Arizona Medicaid Manual.

California

Appeals unrelated to Notices of Adverse Action and actions as a result of an audit conducted pursuant to VSP’s Fraud and Abuse Policy (See above under “Claim Appeals”) must be submitted to us within 365 calendar days from the date of the denial. We’ll review your appeal and send a written response within 45 working days.

If you believe all or part of this claim has been wrongfully denied, you may have the matter reviewed by the California Department of Insurance at: 
California Department of Insurance, Health Claims Bureau
300 South Spring Street, South Tower
Los Angeles, CA 90013, www.insurance.ca.gov 
800.927.4357 (HELP) TDD: 800.482.4833.
 

New Jersey

Appeals submitted from providers in New Jersey must be received within 90 calendar days of original receipt of claim denial. We’ll review your appeal and send a written response within 10 business days from the date of receipt of all information needed to process the appeal.

Our internal second-level appeal is optional for New Jersey doctors. Following state law, New Jersey doctors have the right to use an external second-level appeal after participating in our first-level appeal process.

If you choose this option, we’ll share the cost of the arbitration equally. To initiate this process, submit the appeal in writing to an independent arbitrator listed with the American Arbitration Association and send a copy to us at: VSP Claim Appeals, PO Box 2350, Rancho Cordova, CA 95741-2350.

Here is additional contact information if you need additional information:

American Arbitration Association
Customer Service: 800.778.7879, 212.484.4181
Web site: adr.org
NJ E-mail: casefiling@adr.org

ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for people covered under these plans. If your patient’s employer pays for all or part of the patient’s benefits, the patient has additional appeal rights mandated by ERISA.

Under this law, patients can get copies of all documents, records, and other information relevant to their appeal free of charge.

Once all mandatory appeals have been completed, ERISA patients may have other voluntary alternative dispute resolution options, such as mediation. Your patients may refer to their Evidence of Coverage (EOC) or Standard Plan Description (SPD), contact their local U.S. Department of Labor Office or their State Insurance regulatory agency to find out what’s available.

ERISA patients have the right to contest the decision of the appeal process. Under ERISA Section 502(a)(I)(B), patients have the right to bring civil actions. This right can be exercised when all required reviews of their claims (including the appeal process) have been completed, the claim wasn’t approved (in whole or in part), and a patient disagrees with the outcome.

Some clients require VSP to provide their members with a Vision Benefit Statement (VBS) instead of the current VSP Savings Statement. The VBS provides patients with a summary of the amount they have been charged for the services received and will also provide any denial procedures directly to the patient. If a client requires VSP to provide a VBS, the Patient Record Report will state: Patient will receive Vision Benefit Statement (VBS) directly from VSP; a VSP Savings Statement will not be available.

View a sample of the Vision Benefit Statement.