VSP patients may have the following contact lens benefits:

• Contact Lens Exam Copay with Materials Allowance: The routine eye exam is covered separately. Your patient has a not-to-exceed patient copay for a contact lens exam (prescription and fitting of contact lens) and a separate allowance for contact lens materials.
• Exam And (Combined Contact Lens Allowance): The routine eye exam is covered separately. Your patient has a combined allowance for a contact lens exam and materials.
• Total Allowance: Your patient has a single allowance for the routine eye exam, contact lens exam, and materials.
• Visually Necessary Contact Lenses: With an approved diagnosis or condition, your patient is covered for a contact lens exam and an annual supply of visually necessary contact lenses. See Visually Necessary Contact Lenses in this section for specific benefit coverage criteria.
• Covered Contact Lenses: Your patient is covered for a contact lens exam and an annual supply of contact lenses.

A contact lens exam (prescription and fitting of contact lens) is separate from the WellVision Exam^® and should be provided only to patients who wear or want to wear contact lenses and specifically request a contact lens exam. Contact lens insertion and removal training services are not separately reimbursed.

You can find client-specific exceptions in the special comments section of the Patient Record Report.

Contact Lens Exam Copay with Materials Allowance: Your patient pays an exam copay if you provide a WellVision Exam. Patients who request a contact lens exam pay a contact lens exam copay or 85% of your U&C fees, whichever is less. There is no copay for contact lens materials, which are covered under a separate allowance.

Exam And (Combined Contact Lens Allowance): Patient pays an exam copay if you provide a WellVision Exam. There is no copay for contact lens materials.

Total Allowance: No exam or materials copay is required if materials are purchased on the same date of service. The exam copay may apply if the WellVision Exam is given on a different date of service.

Covered Contact Lenses: Your patient pays the contact lens copay.

VSP covers contact lenses that meet the minimum prescription criteria. Contact lenses that do not meet VSP’s minimum prescription criteria are considered to be plano lenses.

Exclusions

Some materials aren’t covered under VSP’s contact lens benefits. There are no benefits for professional services or materials connected with the following:

• Corneal refractive therapy, orthokeratology, and contact lenses for myopia management are not covered under Necessary Contacts, Covered Contact Lenses, or the VSP Elements Plan. Patients can use their elective contact lenses allowance towards the cost of corneal refractive therapy, orthokeratology, or myopia management contact lens materials only. The contact lens fitting and evaluation portion of the treatment is a private transaction between you and the patient.
• Replacement of lost or damaged lenses
• Modifications of lenses
• Routine maintenance such as polishing, cleaning, etc.
• Refitting after the initial (90-day) fitting period
• Insurance policies or service agreements
• Plano (non-prescription) lenses or lenses that don’t meet our minimum prescription requirement
• Plano lenses to change eye color cosmetically
• Office visits to treat contact lens pathology
• Solutions and other contact lens supplies
• Bandage contact lenses aren’t covered under VSP^® plans but can be billed under Essential Medical Eye Care for eligible patients. See Essential Medical Eye Care in this section.

A contact lens exam and an annual supply of contact lenses are covered in full for patients meeting the established conditions below. Those patients must be eligible for materials on the date of service. Coverage is limited and may require special handling to ensure proper reimbursement. Exam and material (prescription lenses and frame) copays for contact lenses apply unless otherwise specified.

• Nystagmus – H55.00 through H55.09, H81.10 through H81.23, or H81.41 through H81.49
• Anisometropia greater than or equal to 3.00 diopters difference based on the spectacle prescription.
• High ametropia greater than or equal to ±10.00 diopters in either eye based on the spectacle prescription.
• Please see Visually Necessary Contact Lens Specialty Contact Lenses below for a complete listing of covered diagnosis codes.

To submit necessary contact lens claims through eClaim for any of the conditions above, do the following:

Select Necessary Contact Lens as the Contact Lens Reason. Indicate the appropriate diagnosis code and/or spectacle prescription verifying the condition. For anisometropia and/or high ametropia, enter the spectacle prescription on the lab invoice for verification purposes. Not all conditions can be verified on Eyefinity. See Submitting Claims for additional instructions.

Scleral Lenses (For Covered Contacts and Visually Necessary Contacts)

Bill scleral lenses using HCPCS V2530 or V2531. Hybrid contact lenses are not scleral lenses and will not be reimbursed as sclerals. Bill hybrid lenses using V2599.

When submitting a claim for Visually Necessary Contacts using V2531, you must provide the following information in Box 19:

• Type of lens – Scleral
• The scleral lens manufacturer or brand

If this information is missing or incomplete, it will result in claim reimbursement at the V2599 rate.

Other Type of Contact Lenses (For Covered Contacts and Visually Necessary Contacts)

Use HCPCS code V2599 for other types of contact lenses, such as hybrid lenses.

When submitting a claim using V2599 (contact lens, other type) you must provide the following information in Box 19:

• Type of lens
• The lens manufacturer or brand
• For example, hybrid contact lens, SynergEyes^® iD

If the information is missing or incomplete, it will result in claim reimbursement at the V2510 rate.

Piggyback Lenses Benefit

Piggyback lenses are a covered benefit for patients meeting one of the conditions above, and who aren’t able to tolerate rigid gas permeable contact lenses. This requires the use of soft contact lenses and rigid gas permeable contact lenses, in the manner of a piggyback fitting.

When submitting a claim for piggyback lenses, you must provide the following information in Box 19:

• Piggyback lenses

Spectacle lenses to wear over contacts benefit

Contacts with spectacle lenses to wear over contacts are covered benefits for patients with the following conditions:

• Aphakia – H27.00 - H27.03 or Q12.3
• High ametropia greater than or equal to ±10.00 diopters in either eye based on the spectacle prescription.
• Presbyopia – H52.4
• Pseudophakia – Z96.1
• Accommodative disorder
• Binocular function disorder
• Different prism requirements for distance and near vision

A prescription is required for the lenses. Plano lenses aren’t a covered benefit.

When your patient qualifies for spectacle lenses to be worn over contact lenses, request the spectacle lenses claim number at the same time or within 30 days of the contact lens claim submission date. For patients with keratoconus, request a claim number for spectacle lenses to be worn over contact lenses within 12 months of the contact lens claim submission date. Frames are private transaction between you and your patient.

If your patient meets the benefit criteria for visually necessary contact lenses above and also requires spectacle lenses to wear over the contacts, please verify that the above criteria is met, and call VSP at 800.615.1883 to obtain a claim number. Please have the relevant criteria information available when calling.

Submitting Claims

Request a case number when your patient meets the benefit coverage criteria above, but you can’t submit your claim through eClaim at eyefinity.com. To get a case number so you can submit your claim through eClaim, complete a Materials Verification Form, which must include at least one of the qualifying criteria listed above. Please allow five (5) business days for a response. Put your case number in Box 23.

The following situations also require the submittal of a Materials Verification Form:

• NCL claims with DOS over 6 months
• Physical condition of ears or nose which prohibits the use of eyeglasses
• Physical symptoms associated with paraplegia or quadriplegia (be specific)

Fax the Materials Verification Form to us at 916.851.4733. Or mail to VSP, PO Box 385020, Birmingham, AL 35238-5020. You can find the form in the VSPOnline section of eyefinity.com or in the Tools and Forms section of this manual.

Reimbursement for Visually Necessary Contact Lenses

An annual supply of contact lenses is covered in full for patients meeting the stated benefit criteria. We’ll reimburse you:

• Your assigned fee for the examination
• Up to allowed amount for the type and quantity of contacts provided (85% of your U&C fee for the contact lens exam plus U&C fee for contact lens materials)

Do not balance bill your patient the difference between VSP’s allowed amounts and your U&C fee for materials. Exam and material (spectacle lenses and frame) copays apply unless otherwise specified. Any contact lens fitting fees incurred after the initial 90 day period are considered a private matter between you and the patient. Do not submit a separate claim for a contact lens exam.

¹Annual Replacement is 1-2 units. Planned Replacement is 3-360 units. Daily Replacement is 361+ units.

*These services shouldn’t be billed for more than 2 units. If billed with higher unit counts, we’ll pay up to the Annual Replacement lens maximum. Refer to billing instructions for scleral lenses above.

**These services shouldn’t be billed for more than 360 units. If billed with higher unit counts, we’ll pay up to the Planned Replacement lens maximum. Refer to billing instructions for hybrid and proprietary lenses above.

¹Annual Replacement is 1-2 units. Planned Replacement is 3-360 units. Daily Replacement is 361+ units.

*These services shouldn’t be billed for more than 2 units. If billed with higher unit counts, we’ll pay up to the Annual Replacement lens maximum.

**These services shouldn’t be billed for more than 360 units. If billed with higher unit counts, we’ll pay up to the Planned Replacement lens maximum.

Submitting the Claim

Reimbursement

New Mexico doctors: Determine your total fees for services and materials. Bill this amount on the claim.

See Contact Lens Case Management Procedures for contact lens fitting documentation criteria.