Glossary

Terms:	Definition:
Acute EyeCare	A VSP product covering patients who need urgent care.
Administrative Simplification	Administrative Simplification, or Title II of the Health Insurance Portability and Accountability Act (HIPAA), will standardize specific electronic transactions used in the healthcare industry. This requires protecting patient privacy and ensuring the security, integrity and authenticity of health information.
Algorithm	In this context, a step-by-step description of the suggested procedure for monitoring and/or treating certain conditions. Algorithms are intended to provide guidance only; they never replace a doctor’s professional judgment.
Allowance	The maximum amount, in dollars, we will pay toward a certain service.
Authorization	The process of making sure a patient’s eyecare may be covered by VSP. Authorization doesn’t guarantee payment for a service.
Benefit	In this context, the type and amount of coverage for a service.
Birthday Rule	A way to determine the primary vision plan for dependent children covered by more than one plan. In this case, the primary plan is the one held by the parent whose birthday comes first in the calendar year.
Claim	A healthcare provider’s request to a health plan for payment and the necessary accompanying information.
CMS-1500	Formerly HCFA-1500. A federally approved claim form used to record the patient’s condition and bill for services rendered.
Coordination of Benefits	Also called COB. The process of coordinating multiple plans for a single patient visit.
Contract Lab	An optical lab that has signed a contract with us to make lenses for our patients.
Copay	Payment collected from a patient before services are given. Copays vary between plans, clients and levels of coverage.
Coverage	A term showing that the cost of a certain service provided to a patient will be reimbursed by us in part or in full.
CPT Code	“Current Procedural Technology Code.” An identifying code and descriptive term used to report services and procedures.
Credentialing	The process of ensuring our doctors meet standards including current licensing and board certification, as applicable.
CVC	Video Display Terminal. This term is used mainly when talking about our Computer VisionCare plan.
Diabetic Eyecare Program	A VSP product that provides medical eyecare services for patients with Type 1 diabetes.
Dispensing	The process of providing materials, such as lenses, frames and contact lenses to patients.
Eligibility	Whether a patient can get VSP benefits.
Encounter Data	Detailed patient demographic, health and health insurance information collected from a CMS-1500 claim form.
Fee-For-Service Plan (FFS)	Health coverage in which doctors and other providers receive a fee for each service such as an office visit, test, procedure or other healthcare service. The plan will either pay the medical provider directly or reimburse the patient for covered services after the patient has paid the bill and filed an insurance claim. Patients can get medical care from doctors they choose.
First-Time Redo	The one-time remaking of a lens that falls within our first-time redo policy.
Frame Overage	The dollar amount patients must pay when they choose a frame whose cost exceeds both the patient’s wholesale and retail frame allowance.
Gender Rule	A way to designate a primary vision plan for dependent children covered by more than one vision plan. In this case, the father usually holds the primary plan.
Half-Pair Lens enhancemen	Typically refers to a patient lens enhancement when the doctor or patient requests the enhancement on only one lens, rather than a pair of prescription lenses.
HCPCS	HCFA's Common Procedure-Coding System. A list of descriptive terms and identifying codes for reporting medical services given by healthcare providers.
Health Maintenance Organization (HMO)	A type of health plan that provides care through a network of doctors in particular geographic or service areas. HMOs coordinate the healthcare services patients receive.
HEDIS	Healthcare Effectiveness Data and Information Set. A set of standardized measures designed to assess health plan performance.
HIPAA	The Health Insurance Portability and Accountability Act (HIPAA) is federal legislation intended to improve the portability and continuity of health benefits, to ensure greater accountability for healthcare fraud and to simplify administering health insurance.
Independent Lab	An optical lab not under contract with us.
Interim Benefit	A supplemental benefit (offered by some VSP clients) that covers services before the patient’s next eligibility date. Interim benefits particularly apply when there are significant changes in the patient’s prescription.
IVR	Interactive Voice Response. This is our automated system allowing doctors to access patient eligibility and coverage by phone.
Laser VisionCare	A VSP eyecare plan offering coverage for laser procedures.
Lens Enhancements	Cosmetic lens features or enhancements. Patients pay the Patient Copay unless their plans cover that enhancement. Examples of lens enhancements include tints, polycarbonate and anti-reflective coatings.
Medical Record Review	Patient medical records are submitted to VSP and reviewed by OD/MD auditors who verify the exam and treatment for each patient follows established criteria and is properly documented.
Member	A person enrolled in a VSP plan who is the primary insured.
NCQA	National Committee for Quality Assurance. This is an independent, not-for-profit organization setting health plan accreditation standards.
Order of Benefits	The sequence in which benefits are exhausted, beginning with primary plans, secondary plans and then numerically succeeding plans.
Overage	Amount the patient pays the doctor (in addition to the copay) for services and products not covered by any plan.
Medical Record Review	Patient medical records are submitted to VSP and reviewed by OD/MD auditors who verify the exam and treatment for each patient follows established criteria and is properly documented.
PCP	Primary Care Physician. The doctor the patient usually visits.
Preferred Provider Organization (PPO	A fee-for-service option where a member can choose plan-selected providers who have agreements with the plan. When a member uses a PPO provider, they pay less money out-of-pocket for medical service than when they use a non-PPO provider.
Primary Coverage	In coordination of benefits, the primary coverage is held by the person whose benefits will be exhausted before benefits from secondary and other plans are used.
Primary EyeCare	A VSP product that provides supplemental medical eyecare services for the detection, treatment and management of ocular and/or systemic conditions that produce ocular or visual symptoms.
Primary Plan	The plan held by the person whose benefits are exhausted first, following the order of benefits.
Referral	The process doctors use to direct patients to consult with another doctor.
Reimbursement	Money paid to doctors for covered services
Explanation of Payment (EOP)	A statement explaining service payments and adjustments included in VSP doctor reimbursements. Also called an Explanation of Benefits (EOB) or Remittance Advice (RA).
Schedule of Allowances	A list of services patients are covered for, and the amounts to which patients are covered, according to their plans.
Secondary Allowance	The amount available for each benefit when VSP is the secondary plan.
Secondary Coverage	In coordination of benefits, secondary coverage is held by the person whose benefits are used after benefits from the primary plan have been exhausted.
Secondary Plan	The plan held by the person whose benefits are used after primary plan benefits have been used.
Service for Service	The secondary allowance is applied first to the same service or product of the primary plan (exam to exam, lens to lens, frame to frame, etc.). Any benefit amounts remaining after applying the allowance to a like benefit can be used for other services.
Service Verification	The process for making sure a service is covered and we’ll reimburse you for that service before you give that service. You’ll be notified which services need special processing to obtain a case number.
U&C; U&C Fees	Usual and Customary Fees. These are a doctor’s standard, unmodified charges for given services.
VSP Network Doctor	An optometrist or ophthalmologist who’s signed a contract to take part in our doctor network.