When VSP is Primary

Submit the claim as you would in the absence of any other plan.

Submitting the claim electronically:

1.  Get authorizations for both primary and secondary benefits.
2.  On the primary authorization, enter the services performed, calculate the HCPCS codes and enter your usual and customary fee(s).
3.  Mark “No” for question 11d in the Insured section.
4. Enter the secondary authorization number in the VSP COB Coordination of Benefits Secondary Authorization field.

Recognizing the complex nature of COB can be a barrier to adoption. VSP has simplified the process when Medicare, a health plan or a non-VSP insurance carrier is Primary and VSP is Secondary:

• Maximize member benefits – You can now coordinate both their routine and medical benefits (i.e. medical exam and refraction using a WellVision exam benefit and Essential Medical Eye Care).
• Expanded electronic filing capabilities – You can now submit secondary COB claims electronically, regardless of services provided, with new fields to enter the primary plan’s payment (no more paper, just keep a copy of EOP in the patient’s chart).
• Simplified claim submission – you can now coordinate secondary benefits in a single claim submission when VSP is secondary and tertiary or when using the patient’s medical and routine eye care plans (just key the 2nd auth in the COB Secondary Authorization box)

How it works:

If we’re the secondary payor, bill us for your patient’s out-of-pocket expenses. Examples are copays, coinsurance, deductibles on High Deductible Health Plans or charges for non-covered services by the primary carrier.

If a member has medical benefits under another health plan, that plan is primary and VSP is secondary. If you participate on the patient’s health plan, coordinate benefits between the health plan and VSP. In these situations, coordinating benefits will help your patients maximize their coverage. You’re responsible for verifying other coverage, as well as billing and collecting from other carriers.

VSP will coordinate the non-covered portion of the services (exam, refraction, materials) with a patient’s routine benefits, if the claim includes a routine diagnosis – in addition to a medical diagnosis code, if applicable. We’ll only coordinate Essential Medical Eye Care and Diabetic Eyecare Plus Program^SM benefits with services provided for medical eyecare and this requires a medical diagnosis is the first position.

If both routine and medical services were submitted to the primary carrier with corresponding routine and medical diagnosis codes, you can now coordinate using a patient’s VSP routine and medical plans to pay toward patient out-of-pocket expenses. We follow plan policies for reimbursing these charges. However, we don’t pay more for approved services than what you would have received if we were the primary carrier.

Tips:

• If you can verify the health plan or Medicare’s eligible services and non-covered patient responsibility amount at the time of billing, you can now submit the Secondary Plan exam only claim electronically on the same day. You’ll still need to keep a copy of the original claim and Explanation of Payment or Explanation of Benefits in the patient’s file.
• If you are unable to verify the patient responsibility, wait until you receive payment from the health plan or Medicare before submitting the Secondary claim to avoid unnecessary claim corrections, as you are responsible for reconciling payments. For Medicare or Medicaid patients, overpayments must be corrected within 60 days.

Submitting the claim electronically (new eClaim):

1. Provide the same diagnosis and CPT/HCPCS codes to match the claim to insurance carrier.

2. Select Yes (Box 11d) there is another health benefit plan for eyecare. This will open a new section.

• Leave the field for Secondary Authorization blank – unless there is a second VSP plan to COB.

3. Complete the Other Insured section:

• Enter the first and last name of the insured person on the patient’s primary insurance plan in box 9
• Enter “NA” in box 9a
• Enter the patient’s primary insurance plan name in box 9d

4. Scroll to the Services section to enter the following in the COB fields for each service based on your Explanation of Payment (EOP):

• In the Other Ins Allowed field, enter the maximum amount allowed by the other insurance.
• In the Other Ins Paid field, enter the amount paid by the other insurance.
• In the Other Ins Pat Resp field, enter the remaining balance the patient is responsible to pay

• In the Denied or Paid $0.00 Reason drop-down menu, select the reason the primary EOP indicated that the claim was denied or paid $0.00. If the reason isn’t listed, submit on paper.

5. In the Additional Information section, enter “Secondary COB claim” in box 19. Additional Claim Information.

6. If you need a copy of the claim with the COB details, click Print in the top navigation bar; it’s not on the CMS Report or Service Report.

Download our step-by-step guide to filling out your claim electronically

Submitting the Claim on paper

When you receive payment from the primary Vision Plan, submit the following information to us within six months from the issue date of the Explanation of Payment (EOP) or Explanation of Benefits (EOB) of the primary plan (Medicare, Health Plan or Vision Plan):

1. A copy of the EOP indicating patient expenses and/or service denials from the primary carrier. Don’t send a summary.
2. A copy of the original CMS-1500 claim form. Enter VSP’s authorization number in Box 23.
3. If an additional benefit will be used, enter “Tertiary COB auth ########” (additional authorization #) in Box 19.