Billing Vision Insurance for Medically Necessary Contact Lenses

This information has been gathered from other successful offices, and following these guidelines DOES NOT guarantee coverage or payment. Regional accuracy is not guaranteed. Practices are advised to confirm all details with their insurance companies.

VSP EYEMED Visually Necessary Contact Lenses Visually Necessary Contact Lenses • Covered for conditions below • Prior authorization is no longer required, • Patients must be eligible for materials but it’s advisable to check the online portal • Exam and material copays may apply or call to verify the benefits and coverage of each patient. Benefit Coverage Criteria • Must fill out Medically Necessary Contact • Aphakia Lens Claim Form and fax to 866.293.7373. • Nystagmus One benefit per calendar year. • Keratoconus • Aniridia Benefit Coverage Criteria • Corneal transplant • Anisometropia – Select this if spectacle Rx • Hereditary corneal dystrophies has a 3D difference in meridian powers • Anisometropia >= 3.00 D in any meridian - CPT Code – 92310AN • High Ametropia >= 10.00 D in any meridian - ICD-10 Code – H52.3_ • Irregular Astigmatism - Enter U&C Fee • Achromatopsia - Check box V2599 and enter U&C Fee • Albinism • High Ametropia – Select this if spectacle Rx • Polychoria exceeds -10D or +10D in meridian powers • Anisocoria (congenital) in either eye. • Pupillary Abnormalities - CPT Code – 92310HA - Enter U&C Fee Filing the Claim - Check box V2599 and enter U&C Fee. • Claim may be filed electronically on e-Claim • Keratoconus (mild/moderate) – Select this if • No prior authorization needed diagnosis is mild to moderate keratoconus where • Select Necessary Contact Lens as the BCVA through spectacles is worse than 20/25. Contact Lens Reason - CPT Code – 92072 • When submitting a claim there are three - ICD-10 Code – H18.60_ or H18.61_ important components - Enter U&C Fee 1. The Diagnosis Code: Indicate the appropriate - Check box V2599 and enter U&C Fee ICD-10 diagnosis code and/or spectacle • Keratoconus: (advanced/ectasia) prescription verifying the condition - CPT Code: 92072AD 2. The HCPCS Code: Use V2599 for hybrid - ICD-10 Code: H18.62_ or H16.71_ lenses. Use V2531 for scleral lenses. - Check box V2599 and enter U&C Fee When submitting a claim using V2599 or V2531, • Vision Improvement – When Keratoconus you must provide this information in Box 19: is not present, select this for members - Type of lens (e.g., hybrid contact lens) whose vision can be corrected by two - The lens manufacturer and brand lines on the visual acuity chart. Note: If this information is missing or incomplete, - CPT Code – 92310VI it will result in reimbursement at the V2510 rate - Enter U&C Fee 3. The Number of Units: 4 units for hybrid - Check box V2599 and enter U&C Fee lenses which is the planned replacement classification. 2 units for scleral lenses which is the annual replacement classification. More Information: For More Information: Log in at www.eyefinity.com. Click “VSP Online”, click “manuals”, Log in at portal.eyemedvisioncare.com. Click “providers”, click “VSP”. Under “plans and coverage,” click “contact lens click “login/register”, click “manuals”. Click benefit”. Scroll down to “Visually Necessary Contact Lenses”. “Section 9: Special services”. Download “Section 9”. VSP DAVIS VISION SPECTERA

• Policy Manual available at • Must submit Necessary Contact Lens http://cvw1.davisvision.com/forms/staticfiles/ Eligibility Form together with the claim english/provman.pdf paperwork: Must submit Prior Approval Request Form - Fax to 218.285.2935 - Fax to 800.584.2329 - Atn: Raquel Korpi • Verify member eligibility prior to - RE: Necessary Contacts submitting authorization form • The prescribing doctor determines if contact • Must attach supporting documents lenses are necessary based on Spectera (topo, pachy, etc.) Vision Guidelines. The conditions that • If approved Davis Vision will fax the require necessary contact lenses are: authorization utilizing the Request Form - Keratoconus • Bundle service fees, but keep them separate - Irregular Corneal astigmatism from material fees - Aphakia • Contact Lenses may be determined to be - Anisometropia greater than 3.50 Diopters medically necessary in the treatment of the - Acuity less than 20/70 with glasses following nine conditions: and better than 20/70 with contact - Keratoconus lenses - Progressive Myopia - Facial deformity - Anisometropia - Corneal deformity - Post Cataract - Must enter U&C Fee for Fitting fee - Aphakia and Contact lenses. - Pathological Myopia • Following cataract surgery. To correct - Diabetes vision problems that cannot be corrected - Aniseikonia with spectacle lenses. - Aniridia - Corneal Disorders - Post-Traumatic Disorders - Irregular Astigmatism

May 2016