Exam Coverage

Exam Plus patients are covered for a comprehensive eye exam.

Materials

The benefits below are considered a private transaction between you and your patient. Your patient must pay for any additional items.

• Patients are eligible for complete sets of prescription glasses or non-prescription sunglasses from a VSP doctor within 12 months of the last eye exam at 80% of U&C. The benefit:
• Patients are eligible for contact lens exam services (F&E) and follow-up services at 85% U&C. The benefit:
• Is unlimited for 12 months on or following the date of the last eye exam.
• Use professional judgment when evaluating prescriptions from another doctor. You can request an additional routine exam at 80% of U&C.
• Deduct 20% on additional eye exams, including if only a refraction is performed.
• Doesn’t apply to cleaning products or repairs of prescription lenses or frames.
• Applies to services for prescription lenses only.
• Is unlimited for 12 months on or following the date of the last eye exam.
• Use professional judgment when evaluating prescriptions from another doctor. You can request an additional routine exam at 80% of U&C.
• Doesn’t apply to contact lens materials, solutions, cleaning products, or service agreement

Exam Coverage

VSP Exam Plus With Allowance patients are covered for a comprehensive eye exam.

Materials Coverage

Lenses and Frames

Patients are eligible for prescription lens, lens enhancements and/or frame (complete pair not required), plus they have a group-specific schedule of allowances. The lens allowance is applied to the complete lens service—including both the base lens and any lens enhancements selected.

VSP only covers frames that are used for prescription lenses that meet VSP’s minimum prescription criteria (refractive error is at least +/- 0.50 diopter), unless the patient has plano coverage.

The benefit is available for 12 months on or following the date of the last covered eye exam, however the allowance schedule apples only once. Deduct 20% from the materials first, then apply the allowance.

Contact Lenses

Charge patients with Elective Contact Lens (ECL) or Visually Necessary Contact Lens (NCL) coverage 85% U&C for contact lens exam services (evaluation/fitting services and follow-up services). You may charge your U&C fees for contact lens materials. Elective or visually necessary contact lenses are chosen in place of a complete set of prescription glasses. Your patient must pay any costs over the allowances listed in their client-specific schedule of allowances.

Lab

Lab work is handled privately. You may provide lenses through any lab, including in-office labs.

Value-Added Benefits

The Value-Added benefits below are considered a private transaction between you and your patient. Your patient must pay for any additional items.

• Patients are eligible for additional complete pairs of prescription glasses and non-prescription sunglasses and blue light filtering glasses, from any VSP doctor within 12 months of the last eye exam at 80% of U&C. The benefit:
• Patients are eligible for contact lens exam services (F&E) and follow-up services at 85% of U&C. The benefit:
• Is unlimited for 12 months on or following the date of the last eye exam.
• Use professional judgment when evaluating prescriptions from another doctor. You can request an additional routine exam at 80% of U&C.
• Deduct 20% on additional eye exams, including if only a refraction is performed.
• Doesn’t apply to cleaning products or repairs of prescription lenses or frames.
• Applies to services for prescription lenses only.
• Is unlimited for 12 months on or following the date of the last eye exam.
• Use professional judgment when evaluating prescriptions from another doctor.
• Doesn’t apply to contact lens materials, solutions, cleaning products, or service agreements.

Submitting Claims/Billing & Reimbursement

VSP Exam Plus With Allowances

• Your patient pays the amount above their allowance. You may charge your U&C fees for contact lens materials. Progressive lenses are reimbursed at the bifocal allowance.
• For patients with combined allowances, bill all services at the same time so your patients get their full benefits. Remaining allowances can’t be carried forward. The combined allowance applies to only one set of services. Your patients may use their benefits for a complete pair of prescription glasses or contact lens fitting/materials.

Submitting the Claim Electronically

Glasses:

Bill using our electronic claims submission system.

• Complete the Invoice Services page and select Non-VSP lab (Private Invoice).
• Click on the Calculate HCPCS and Continue button.
• Complete the Diagnosis and Services page by entering your full U&C fees next to the appropriate CPT/HCPCS code.

Contact Lenses:

Bill using our electronic claims submission system.

• Choose the type of contacts dispensed.
• If contact lens evaluation/fitting services were provided, show this in the dropdown.
• Click on the Calculate HCPCS and Continue button.
• Complete the Diagnosis and Services page by entering your full U&C fees next to the appropriate CPT/HCPCS code.
• Please see the Necessary Contact Lens Benefit Criteria section of your VSP Provider Reference Manual for more information regarding benefit criteria and claim submission.

Submitting the Claim on Paper

Glasses:

• Enter your full U&C fees next to the right CPT/HCPCS code.
• Complete the CMS-1500 Claim Form by entering your full U&C fees next to the right CPT/HCPCS code for lens and frame.
• Enter all eight digits of the authorization number in Box 23.

Contact Lenses

• Enter your full U&C fees next to the right CPT/HCPCS code.
• Select the type of contacts dispensed.
• Enter all eight digits of the authorization number in Box 23.

• The program includes access to either Photorefractive Keratectomy (PRK) or Laser In-Situ Keratomileusis (LASIK) at a reduced cost, up to a maximum fee to the patient of $1,500 per eye for PRK, $1,800 per eye for LASIK, and $2,300 per eye for Custom LASIK with wavefront technology using microkeratome, Custom PRK, or Bladeless LASIK.
•  Members receive a complimentary screening as well as pre-operative and post-operative services through participating VSP doctors.
• If the laser center is offering a temporary price reduction, VSP members will get 5% off the advertised price if that’s less than the usual discount price.
• Please see the Laser VisionCare page under Programs on VSPOnline at eyefinity.com for information on how to participate or for a list of participating facilities.

See Services Subject to Review/Audit for information regarding material record keeping requirements.