Last Updated: N/A Medicaid Plan

Effective Date: N/A

NOTE: This manual remains the sole and exclusive property of VSP®. The information contained in this manual is confidential and proprietary, and the VSP network provider is granted a limited personal and nontransferrable license for use of the content of this manual during participation on the VSP network. The contents of this manual may not be used, copied, and/or reproduced for any other purpose, or disclosed and/or disseminated to any third party for any purpose whatsoever, without the prior written consent of VSP. If, for any reason, the manual recipient no longer participates on the VSP network, the doctor hereby agrees, and is directed, to immediately destroy this manual, all copies, and any and all amendments and addenda that may be issued by VSP from time to time.

medicaid plan Table of content

VSP’s Medicaid Plan

VSP’s Medicaid Plan 1.1

Enrollment/Doctor Participation

Enrollment/Doctor Participation 2.1

Exam Coverage

Exam Coverage 3.1

Materials Coverage

Materials Coverage 4.1

Laboratory

Laboratory 5.1

Submitting Claims/Billing, Reimbursement, & Appeals

Submitting Claims/Billing, Reimbursement, & Appeals 6.1

Medicaid Client Details

Medicaid Client Details 7.1

Medicaid Fee Schedules

Medicaid Fee Schedules 8.1

VSP’s Medicaid Plan

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

Confidential

VSP’s Medicaid Plan (AZ)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (CA)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (IL)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (MI)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual

VSP’s Medicaid Plan (NV)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (NH)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (NY)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (OH)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (OR)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (SC)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (UT)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (VA)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (WA)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

VSP’s Medicaid Plan (WV)

VSP’s Medicaid Plan is based on contracts with health care organizations (clients) to provide the vision care portion of the state’s Medicaid program.

Clients are required to provide the minimum benefits specified by your state’s Medicaid program, but may also offer enhanced benefits.

Please refer to Client Detail pages and/or Medicaid Fee Schedules for details about administration of basic state benefits. For state information, refer to the State Medicaid Manual.

Enrollment/Doctor Participation

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Enrollment/Doctor Participation (AZ)

Participation is voluntary. Only VSP doctors who have signed a Medicaid Plan Acknowledgment may provide services to Medicaid Plan members. All participating doctors are required to have a state Medicaid identification number.

Enrollment/Doctor Participation (CA)

Enrollment/Doctor Participation (IL)

Enrollment/Doctor Participation (MI)

Enrollment/Doctor Participation (NV)

Enrollment/Doctor Participation (NH)

Enrollment/Doctor Participation (NY)

Enrollment/Doctor Participation (OH)

Enrollment/Doctor Participation (OR)

Enrollment/Doctor Participation (SC)

Enrollment/Doctor Participation (UT)

Enrollment/Doctor Participation (VA)

Enrollment/Doctor Participation (WA)

Enrollment/Doctor Participation (WV)

Cultural Competence Training (AZ)

All providers who serve Medicaid patients are required to complete and attest to having completed cultural competency training annually. Network doctors who own their practice are required to attest that they and their staff, including all employee doctors, completed the training. VSP makes this training available on VSPOnline and sends via email annually. You may take it at any time at least once per calendar year. The training modules include:

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

If you completed cultural competence training from another source, you may attest to that in lieu of taking VSP-provided training. The attestation is available on VSPOnline in the Cultural Competency training section or can be accessed from the link in the annual email reminder.

Cultural Competence Training (CA)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (IL)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (MI)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (NV)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (NH)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (NY)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (OH)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (OR)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (SC)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (UT)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (VA)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (WA)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Cultural Competence Training (WV)

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Eligibility & Authorization (AZ)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

VSP’s Electronic Claim Submission System—Enter member’s Social Security Number or client-assigned ID number using eyefinity’s website and select “Check Patient Eligibility” to access eligible plans. You may wish to print the plan information to discuss plan coverages with your patients.

Customer Service—Call VSP at 800.615.1883. You may select “1” to contact our automated Interactive Voice Response (IVR) system, or you may speak with a Customer Service Representative who will verify the patient’s current eligibility, provide plan information, and issue an authorization.

Eligibility & Authorization (CA)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (IL)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (MI)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (NV)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (NH)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (NY)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (OH)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (OR)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (SC)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (UT)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (VA)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (WA)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

Eligibility & Authorization (WV)

When you contact VSP for an authorization, please provide the following information:

Last four-digits of the member’s Social Security Number and date of birth or the entire client-assigned ID number
Member’s Medicaid number if different from Social Security Number
Patient’s date of birth
Patient’s HMO name

There are several ways to obtain an authorization:

(AZ)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(CA)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(IL)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(MI)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(NV)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(NH)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(NY)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(OH)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(OR)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(SC)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(UT)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(VA)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

(WA)

Note:

When the member’s eligibility has been verified, VSP will provide an authorization number that is effective through the last day of the current month.

Coordination of Benefits (WV)

If the Medicaid patient has vision care coverage through any carrier other than VSP or another VSP plan, you must bill that carrier or the other VSP plan first. The VSP Medicaid Plan should be billed as secondary, where appropriate. For electronic claim submission, be sure to provide the patient’s responsibility for exam and refraction separately.

Coordination of Benefits (AZ)

Coordination of Benefits (CA)

Coordination of Benefits (IL)

Coordination of Benefits (MI)

Coordination of Benefits (NV)

Coordination of Benefits (NH)

Coordination of Benefits (NY)

Coordination of Benefits (OH)

Coordination of Benefits (OR)

Coordination of Benefits (SC)

Coordination of Benefits (UT)

Coordination of Benefits (VA)

Coordination of Benefits (WA)

Exam Coverage

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

Exam Coverage (AZ)

Routine eye exam coverage and timeframes are established by State regulations.

In addition to coverage for routine vision care services, Medicaid members are typically covered for services under Essential Medical Eye Care or Integrated Primary EyeCare Program. Any exceptions to this coverage are described in the Client Detail pages and/or the Fee Schedule.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (CA)

Routine eye exam coverage and timeframes are established by State regulations.
In addition to coverage for routine vision care services, Medicaid members are typically covered for services under Essential Medical Eye Care or Integrated Primary EyeCare Program. Any exceptions to this coverage are described in the Client Detail pages and/or the Fee Schedule.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (IL)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (MI)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (NV)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (NH)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (NY)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (OH)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (OR)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (SC)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (UT)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (VA)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (WA)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Exam Coverage (WV)

Routine eye exam coverage and timeframes are established by State regulations.

For Telemedicine information refer to: Telemedicine.

Referrals (AZ)

Follow all referral protocols set forth by your patient’s health plan for any services beyond the scope of the patient’s VSP plan. Typically, an HMO requires that patient referrals be coordinated by the primary care physician (PCP). However, a PPO usually allows patients to receive care from any medical provider without a PCP referral. Check Client Detail pages for any specific instructions or exceptions.

Referrals (CA)

Referrals (IL)

Referrals (MI)

Referrals (NV)

Referrals (NH)

Referrals (NY)

Referrals (OH)

Referrals (OR)

Referrals (SC)

Referrals (UT)

Referrals (VA)

Referrals (WA)

Referrals (WV)

HEDIS and Eye Exams for Patients with Diabetes (AZ)

The Healthcare Effectiveness Data and Information Set (HEDIS^®) is one of healthcare’s most widely used performance improvement tools. The National Committee for Quality Assurance (NCQA) collects HEDIS data from health plans and other healthcare organizations to create annual health outcome surveys. Health plans use HEDIS data to measure performance and identify opportunities for improvement.

HEDIS includes more than 90 measures across multiple domains of care. These measures relate to public health issues, including (and not limited to) asthma medication use, blood pressure control, cancer screening, diabetes care, heart disease, and smoking and tobacco use cessation.

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Eye Exam for Patients With Diabetes (EED) is a specific HEDIS measure that requires health plans offering commercial, Medicaid, and Medicare plans to report the percentage of members with diabetes who had a dilated or retinal eye exam.

Measurement Definition:
Patients ages 18–75 with diabetes (Type 1 or Type 2) who received screening or monitoring for diabetic retinal eye disease:

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (CA)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Measurement Definition:
Patients ages 18–75 with diabetes (Type 1 or Type 2) who received screening or monitoring for diabetic retinal eye disease:

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (IL)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (MI)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (NV)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (NH)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (NY)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (OH)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (OR)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (SC)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (UT)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (VA)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Current Procedural Terminology (CPT^®) Category II codes are informational, supplemental tracking codes that can be used for quality and performance measurement. These codes are intended to facilitate data collection about the quality of care for certain services (e.g., dilated or retinal eye exam) that support performance measures (e.g., Eye Exam for Patients With Diabetes (EED) HEDIS performance measure).

When VSP members with diabetes receive a dilated or retinal eye exam from a network doctor, in addition to billing the exam CPT code, VSP instructs doctors to bill the appropriate supplemental CPT Category II code, which can be used for HEDIS performance measurement.

Including HEDIS supplemental data on VSP claims strengthens the role doctors of optometry have in their patients' healthcare and highlights the impact they have on protecting their patients' vision and overall health. In addition, when VSP network doctors include CPT Category II codes on claims, this data can be securely delivered to VSP health plan clients, reducing the administrative burden of medical record chart reviews for doctors and their staff.

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

HEDIS and Eye Exams for Patients with Diabetes (WA)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

HEDIS and Eye Exams for Patients with Diabetes (WV)

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Retinal or dilated eye exam by an eye care professional in the measurement year or,
A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(AZ)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(CA)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(IL)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(MI)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(NV)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(NH)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(NY)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(OH)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(OR)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(SC)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(UT)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(VA)

When billing dilated or retinal eye exams for VSP patients with diabetes, include the appropriate supplemental CPT Category II code, for the Eye Exam for Patients With Diabetes (EED) - HEDIS performance measure:

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(WA)

What are CPT Category II Codes?

CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
Category II codes are not to be used as a substitute for Category I codes.
CPT Category II codes are for reporting purposes only and are not separately reimbursable.

What are CPT Category II Codes?

Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
If you receive a claim denial, your reporting code will still be included in the quality measure.

(WV)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(CA)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(IL)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(MI)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(NV)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(NH)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(NY)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(OH)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(OR)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(SC)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(UT)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

(WA)

2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy

2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy

2026F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy

2033F

Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy

3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA)

Arizona CONTENT Test DARON (AZ)

TESTING FOR PRINT

Materials Coverage

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Materials Coverage (AZ)

Materials Coverage (CA)

Materials Coverage (IL)

Materials Coverage (MI)

Materials Coverage (NV)

Materials Coverage (NH)

Materials Coverage (NY)

Materials Coverage (OH)

Materials Coverage (OR)

Materials Coverage (SC)

Materials Coverage (UT)

Materials Coverage (VA)

Materials Coverage (WA)

Materials Coverage (WV)

(AZ)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(CA)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client

(IL)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(MI)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(NV)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(NH)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(NY)

(OH)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(OR)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(SC)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(UT)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(VA)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(WA)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(WV)

Note:

Please refer to the Patient Record Report, authorization, or Client Detail pages to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

Lenses (AZ)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (CA)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (IL)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (MI)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (NV)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (NH)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (NY)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (OH)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (OR)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (SC)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (UT)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (VA)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (WA)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Lenses (WV)

Lenses are available to the patient based on state regulations.

Covered basic lenses are established by state regulations.

For more information, please refer to your Client Detail pages and/or Fee Schedule.

Dispensing of Spectacles (AZ)

If a covered benefit, a dispensing fee may only be billed with a complete set of eyeglasses (frame and lenses). Please refer to your state provider manual for eligibility and state-specific guidelines.

Dispensing of Spectacles (CA)

Dispensing of Spectacles (IL)

Dispensing of Spectacles (MI)

Dispensing of Spectacles (NV)

Dispensing of Spectacles (NH)

Dispensing of Spectacles (NY)

Dispensing of Spectacles (OH)

Dispensing of Spectacles (OR)

Dispensing of Spectacles (SC)

Dispensing of Spectacles (UT)

Dispensing of Spectacles (VA)

Dispensing of Spectacles (WA)

Dispensing of Spectacles (WV)

Repair and Refitting Spectacles (AZ)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (CA)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (IL)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (MI)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (NV)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (NH)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (NY)

f a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (OH)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (OR)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (SC)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (UT)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (VA)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (WA)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Repair and Refitting Spectacles (WV)

If a covered benefit, bill repairs to eyeglasses using CPT code 92370 (repair and refitting of spectacles) or CPT code 92371 (repair of spectacle prosthesis for aphakia).

Do not bill a dispensing code for repairs.

Repair and refitting codes cannot be billed with material HCPCS codes (e.g., V2020) on the same date of service.

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (AZ)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (CA)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (IL)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines

Replacement (MI)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (NV)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (NH)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines

Frames (NY)

Frame coverage is based on state regulations. Medicaid plans have an established allowance for the purchase of a new frame. For further information refer to your Client Detail pages and/or Fee Schedule.

Replacement (OH)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (OR)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (SC)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (UT)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (VA)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (WA)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Replacement (WV)

If a covered benefit, bill replacement frame and lenses using the appropriate frame or lens HCPCS code. Do not bill a dispensing code for replacement of just the frame or lenses.

A dispensing fee may only be billed, if you are replacing a complete set of eyeglasses (frame and lenses).

Please refer to your state provider manual for eligibility and state-specific guidelines.

Frames (AZ)

Frames (CA)

Frames (IL)

Frames (MI)

Frames (NV)

Frames (NH)

Visually Necessary Contact Lenses (NY)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Frames (OH)

Frames (OR)

Frames (SC)

Frames (UT)

Frames (VA)

Frames (WA)

Frames (WV)

Visually Necessary Contact Lenses (AZ)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (CA)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (IL)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (MI)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (NV)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (NH)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

(NY)

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

Visually Necessary Contact Lenses (OH)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (OR)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (SC)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (UT)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (VA)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (WA)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Visually Necessary Contact Lenses (WV)

If a covered benefit, refer to Client Detail pages as specific criteria applies.

Laboratory

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Laboratory (AZ)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.Contract labs that have agreed to provide lenses at a reduced price for VSP are identified in the National Contract Lab List in your VSP Provider Reference Manual. When using a contract lab on this list, please write “VSP Medicaid” and the authorization number on the private invoice to ensure reduced VSP Medicaid materials prices.

Laboratory (CA)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the California Medi-Cal Client Details page.

Contract labs that have agreed to provide lenses at a reduced price for VSP are identified in the National Contract Lab List in your VSP Provider Reference Manual. When using a contract lab on this list, please write “VSP Medicaid” and the authorization number on the private invoice to ensure reduced VSP Medicaid materials prices.

Laboratory (IL)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (MI)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (NV)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (NH)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (NY)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (OH)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

VSP’s Medicaid Plan (OR)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages. Contract labs that have agreed to provide lenses at a reduced price for VSP are identified in the National Contract Lab List in your VSP Provider Reference Manual. When using a contract lab on this list, please write “VSP Medicaid” and the authorization number on the private invoice to ensure reduced VSP Medicaid materials prices.

Laboratory (SC)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (UT)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (VA)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Laboratory (WV)

You may use any lab of your choice on a private invoice basis or fabricate your own materials. Exceptions are noted in the Client Detail pages.

Lab Price Schedule (AZ)

Price Schedule (CA)

Lab Price Schedule (IL)

Lab Price Schedule (MI)

Lab Price Schedule (NV)

Lab Price Schedule (NH)

Lab Price Schedule (NY)

Lab Price Schedule (OH)

Lab Price Schedule (OR)

Lab Price Schedule (SC)

Lab Price Schedule (UT)

Lab Price Schedule (VA)

Lab Price Schedule (WV)

(AZ)

Note:

The lab price schedule below is valid for Medicaid Plan prescriptions only. Please refer to the patient’s authorization and the Medicaid Fee Schedule to determine if any exceptions are covered by your state Medicaid Plan and/or by the client.

(CA)

Note:

(IL)

Note:

(MI)

Note:

(NV)

Note:

(NH)

Note:

(NY)

Note:

(OH)

Note:

(OR)

Note:

(SC)

Note:

(UT)

Note:

(VA)

Note:

(west-virginia)

Note:

(AZ)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(CA)

Bill all allowable items not listed below at your private add-on prices.

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add;	$30.45per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(IL)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(MI)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(NV)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(NH)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(NY)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(OH)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(OR)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(SC)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(UT)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(VA)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(WV)

Cost

Single Vision	$12.15 per pair
Bifocals	$21.55 per pair
Trifocals	$30.55 per pair
Covered Items	Single Vision	Multifocal
For higher powers add:	$3.65 per lens	$4.15 per lens
For lenticular add:	$11.85 per lens	$13.80 per lens
For slab off add:	$30.45 per lens	$30.45 per lens
For prism add:	$1.85 per lens	$1.85 per lens

(AZ)

Note:

Laboratories will charge your office on a private invoice basis. All items not listed are billed at the laboratory’s private add-on prices. Doctor redos are billed by the laboratory at 50% of the scheduled fees.

(CA)

Note:

(IL)

Note:

(MI)

Note:

(NV)

Note:

(NH)

Note:

(NY)

Note:

(OH)

Note:

(OR)

Note:

(SC)

Note:

(UT)

Note:

(VA)

Note:

(WV)

Note:

Submitting Claims/Billing, Reimbursement, & Appeals

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Submitting Claims/Billing, Reimbursement, & Appeals (AZ)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (CA)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (IL)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (MI)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (NV)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (NH)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (NY)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (OH)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (OR)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (SC)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (UT)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (VA)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (WA)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

Submitting Claims/Billing & Reimbursement (WV)

The filing limit for submitting claims in most states is 180 days from the date of service. Exceptions are noted in the Client Detail pages.

Submit Medicaid claims:

Electronically through eClaim on eyefinity.com.
Via paper on a typewritten or computer-generated standard CMS-1500 form.
Enter the authorization number in Box 23 of the CMS-1500 form. Use the appropriate Place of Service and Type of Service codes from your state Medicaid manual, and submit the CMS-1500 form directly to VSP for processing after providing services. It is not necessary to include the lab’s invoice for materials.

VSP will only reimburse claims received for patients who are eligible at the time of service.

All Medicaid claims must be billed with the appropriate diagnosis codes:

(AZ)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(CA)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(IL)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(MI)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(NH)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(NY)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(OH)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(OR)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(SC)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(UT)

Exams or Materials:

Hypermetropia, right eye

Hypermetropia, left eye

Hypermetropia, bilateral

Myopia, right eye

Myopia, left eye

Myopia, bilateral

Unspecified astigmatism, right eye

Unspecified astigmatism, left eye

Unspecified astigmatism, bilateral

Irregular astigmatism, right eye

Irregular astigmatism, left eye

Irregular astigmatism, bilateral

Regular astigmatism, right eye

Regular astigmatism, left eye

Regular astigmatism, bilateral

Anisometropia

Aniseikonia

Presbyopia

Internal ophthalmoplegia (complete) (total), right eye

Internal ophthalmoplegia (complete) (total), left eye

Internal ophthalmoplegia (complete) (total), bilateral

Paresis of accommodation, right eye

Paresis of accommodation, left eye

Paresis of accommodation, bilateral

Spasm of accommodation, right eye

Spasm of accommodation, left eye

Spasm of accommodation, bilateral

Other disorders of refraction

Unspecified disorder of refraction

Unspecified amblyopia, right eye

Unspecified amblyopia, left eye

Unspecified amblyopia, bilateral

Deprivation amblyopia, right eye

Deprivation amblyopia, left eye

Deprivation amblyopia, bilateral

Refractive amblyopia, right eye

Refractive amblyopia, left eye

Refractive amblyopia, bilateral

Strabismic amblyopia, right eye

Strabismic amblyopia, left eye

Strabismic amblyopia, bilateral

Visual discomfort, right eye

Visual discomfort, left eye

Visual discomfort, bilateral

Aphakia, right eye

Aphakia, left eye

Aphakia, bilateral

Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.

Paralytic Strabismus

Other strabismus

Other disorders of binocular movement

H52.01

H52.02

H52.03

H52.11

H52.12

H52.13

H52.201

H52.202

H52.203

H52.211

H52.212

H52.213

H52.221

H52.222

H52.223

H52.31

H52.32

H52.4

H52.511

H52.512

H52.513

H52.521

H52.522

H52.523

H52.531

H52.532

H52.533

H52.6

H52.7

H53.001

H53.002

H53.003

H53.011

H53.012

H53.013

H53.021

H53.022

H53.023

H53.031

H53.032

H53.033

H53.141

H53.142

H53.143

H27.01

H27.02

H27.03

Z96.1

H49.01 –

H49.9

H50.00 –

H50.9

H51.0 –

H51.9

(VA)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(WA)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(WV)

Exams:

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
Z01.020	Encounter for examination of eyes and vision following failed vision screening without abnormal findings
Z01.021	Encounter for examination of eyes and vision following failed vision screening with abnormal findings
Z13.5	Encounter for screening for eye and ear disorders
Z46.0	Encounter for fitting and adjustment of spectacles and contact lenses

(AZ)

Exams or Materials

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(CA)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(IL)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(MI)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(NV)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(NH)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(NY)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(OH)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(OR)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(SC)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

()

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(VA)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(WA)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(WV)

Exams or Materials:

H52.01	Hypermetropia, right eye
H52.02	Hypermetropia, left eye
H52.03	Hypermetropia, bilateral
H52.11	Myopia, right eye
H52.12	Myopia, left eye
H52.13	Myopia, bilateral
H52.201	Unspecified astigmatism, right eye
H52.202	Unspecified astigmatism, left eye
H52.203	Unspecified astigmatism, bilateral
H52.211	Irregular astigmatism, right eye
H52.212	Irregular astigmatism, left eye
H52.213	Irregular astigmatism, bilateral
H52.221	Regular astigmatism, right eye
H52.222	Regular astigmatism, left eye
H52.223	Regular astigmatism, bilateral
H52.31	Anisometropia
H52.32	Aniseikonia
H52.4	Presbyopia
H52.511	Internal ophthalmoplegia (complete) (total), right eye
H52.512	Internal ophthalmoplegia (complete) (total), left eye
H52.513	Internal ophthalmoplegia (complete) (total), bilateral
H52.521	Paresis of accommodation, right eye
H52.522	Paresis of accommodation, left eye
H52.523	Paresis of accommodation, bilateral
H52.531	Spasm of accommodation, right eye
H52.532	Spasm of accommodation, left eye
H52.533	Spasm of accommodation, bilateral
H52.6	Other disorders of refraction
H52.7	Unspecified disorder of refraction
H53.001	Unspecified amblyopia, right eye
H53.002	Unspecified amblyopia, left eye
H53.003	Unspecified amblyopia, bilateral
H53.011	Deprivation amblyopia, right eye
H53.012	Deprivation amblyopia, left eye
H53.013	Deprivation amblyopia, bilateral
H53.021	Refractive amblyopia, right eye
H53.022	Refractive amblyopia, left eye
H53.023	Refractive amblyopia, bilateral
H53.031	Strabismic amblyopia, right eye
H53.032	Strabismic amblyopia, left eye
H53.033	Strabismic amblyopia, bilateral
H53.141	Visual discomfort, right eye
H53.142	Visual discomfort, left eye
H53.143	Visual discomfort, bilateral
H27.01	Aphakia, right eye
H27.02	Aphakia, left eye
H27.03	Aphakia, bilateral
Z96.1	Presence of intraocular lens - COB only, will be accepted without refractive error diagnosis.
H49.01 – H49.9	Paralytic Strabismus
H50.00 – H50.9	Other strabismus
H51.0 – H51.9	Other disorders of binocular movement

(AZ)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care fee schedule for the state in which you reside.

Claim Status and CorrectionsTo check the status of a claim, call VSP at 800.615.1883 or access eyefinity.com.

For claim corrections, such as a diagnosis code, billed amount or service code, call VSP at 800.615.1883 or complete the claim correction form on eyefinity.com.

To dispute or appeal a claim based on a claim denial or dissatisfaction with a claim payment, you may challenge the claim denial or adjudication by filing a formal claim dispute or appeal.

(CA)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

Coordination of Benefits (IL)

Coordination of benefits is available in most states. Exceptions are noted in the Client Detail pages. If the patient has other vision coverage, coordinate benefits and bill the other carrier. Medicaid is the payor of last resort.

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

(MI)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(NV)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(NH)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(NY)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(OH)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(OR)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(SC)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

Coordination of Benefits (UT)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (VA)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

(WA)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

(WV)

Any exceptions are noted in the Client Detail pages.

Medical eyecare services performed in bordering states are reimbursed per Essential Medical Eye Care Medicaid fee schedule for the state in which you reside.

You are responsible for verifying the accuracy of your payment. For Medicaid patients, overpayments must be corrected within 60 days.

Corrected Claims or Claims Resubmission (AZ)

All AHCCCS Providers of services to AZ Medicaid must correct and submit clean claim no later than 12 months from the date of service or 12 months after the date of eligibility posting, whichever is later, including the contact number and address to submit the information currently identified on your RA.

Coordination of Benefits (CA)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

(IL)

Note:

Enter exam and refraction separately with this exact language in box 19: “secondary COB claim patient resp EXAM $XX.XX REFRACTION $XX.XX.” (Indicate the dollar amount of the patient’s responsibility in place of the XX.XX).

Coordination of Benefits (MI)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (NV)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (NH)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (NY)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (OH)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (OR)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (SC)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

(UT)

Note:

(VA)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

Coordination of Benefits (WA)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

Coordination of Benefits (WV)

For Electronic Claims

Exam only claims (with or without a refraction) can be submitted electronically as long as a routine or refractive diagnosis is present,
When you receive payment from the primary plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the primary plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

(AZ)

Note:

(CA)

Note:

(IL)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(MI)

Note:

(NV)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(NH)

Note:

(NY)

Note:

(OH)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(OR)

Note:

(SC)

Note:

(UT)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(WA)

Note:

(WV)

Note:

Filing a Claim Dispute (AZ)

To dispute or appeal a claim based on a claim denial or dissatisfaction with a claim payment, you may challenge the claim denial or adjudication by filing a formal claim dispute or appeal.

If you wish to file a claim dispute or appeal, follow the instructions provided below. Appeals must be received within sixty (60) calendar days for Arizona Medicaid members.

All claim disputes related to a claim for covered services of Arizona Health Care Cost Containment System (AHCCCS) member must be filed in writing to VSP and must be received:

no later than 12 months from the date of service;
12 months after the date of eligibility posting; or
within sixty (60) days after the payment, denial or recoupment of timely claims submission, whichever is later.

Incomplete appeals will be returned.

Mail: Send appeals to: VSP Claim Appeals, PO Box 2350, Rancho Cordova, CA 95741-2350.

Online: Complete the Provider Dispute Resolution Request Form available in the Forms Library under Administration on VSPOnline on eyefinity.com.

(CA)

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(MI)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(NH)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(NY)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(OR)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(SC)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(WA)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

(WV)

For Paper Claims

When you receive payment from the primary plan, send a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan, to VSP. Don’t send a summary.

Refer to the Coordination of Benefits (COB) section of the VSP Manual for complete information.

Medicaid Client Details

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Arizona Medicaid Client Details (AZ)

California Medicaid Client Details (CA)

Illinois Medicaid Client Details (IL)

Michigan Medicaid Client Details (MI)

Nevada Medicaid Client Details (NV)

New Hampshire Medicaid Client Details (NH)

New York Medicaid Client Details (NY)

Ohio Medicaid Client Details (OH)

VSP Oregon Medicaid Client Details (OR)

South Carolina Medicaid Client Details (SC)

Utah Medicaid Client Details (UT)

Virginia Medicaid Client Details (VA)

Washington Medicaid Client Details (WA)

Patients Eligibility for Services

Please review the benefit details below.

Benefit Type	Member Group	Frequency	Comment
Exam Benefit	Children (ages 0 – 20)	Eligible for exam every 12 months.
Exam Benefit	Adults (ages 21 and over)	Eligible for exam every 24 months.
Material Benefit	Children (ages 0 – 20)	Order hardware from the agency’s contractor CI Optical. Please refer to the Washington Apple Health Vision Hardware Program billing guide for further information.	VSP will pay a material dispensing fee for the fitting of spectacles or the fitting of contact lenses. Please refer to the VSP Washington Medicaid Plan Professional Fee Schedule.
Material Benefit	Adults (ages 21 and over) *Updated effective 7/1/21	Eyeglass frames and lenses are not covered. You can purchase eyeglass frames and lenses through Airway Heights Optical at a discounted price. Please refer to the Washington State Health Care Authority for further information.	VSP will pay a material dispensing fee for the fitting of spectacles or the fitting of contact lenses. Please refer to the VSP Washington Medicaid Plan Professional Fee Schedule.

West Virginia Medicaid Client Details (WV)

Effective April 30, 2022, VSP will no longer administer vision benefits for Unicare West Virginia, providers have 180 days from the date of service to submit claims to VSP.

Medicaid Appointment Availability Requirements (AZ)

The following access standards are required for participation in the VSP Arizona Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 calendar days for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

CA Cultural Competence and Compliance Training (CA)

All Network doctors who serve CA Medicaid patients are required by the California Department of Health Care Services (DHCS), to complete and attest to having completed, training which is provided by VSP prior to being added to the VSP Medicaid network and annually thereafter. Network doctors who own their practice are required to attest annually that they and their staff, including employee doctors, have completed the training. The training modules include:

Cultural Competency
Critical Incident
General Compliance
Fraud Waste and Abuse
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Training will be emailed to practices annually to complete and attest to completion. Network doctors must ensure and attest that their employees have completed the training, and to provide evidence of such completion if requested by VSP. Electronic signatures on training attestations (which will also be in the email) are required to show proof of completion.

Providers must retain records of training for a period of 10 years.

Member Identification Number (IL)

Health Care Services Corporation (Blue Cross Community Health Plans) members are reported by a unique numeric ID number.

The state of Illinois requires providers to enroll in the web-based system known as Illinois Medicaid Program Advanced Cloud Technology (IMPACT) to participate in the Department’s Medical Programs. Refer to the Handbook for Providers of Optometric Services, Chapter 0-200 – Policy and Procedures for enrollment requirements.

Refer to the Illinois Department of Healthcare and Family Services, IMPACT website at the following: https://www2.illinois.gov/hfs/impact/Pages/default.aspx

Member Identification Number (MI)

Aetna Better Health members are reported by a 10-digit identification number.

Molina Healthcare members are reported by a 10 or 12-digit identification number.

Member Identification Number (NV)

Members are reported by a numeric 11 digit ID number.

Member Identification Number (NH)

Member ID starts with two alpha characters (NH), followed by seven numbers (e.g., NH1234567)

Member Identification Number (NY)

Members are reported as follows:

Centers Plan for Healthy Living – 11-digit all numeric ID number (not Client Identification Number), located on the health plan card

Prime Health Choice – 9-digit Social Security number

Member Identification Number (OH)

Members are reported by a 12-digit numeric identification number.

Members having limited English or reading proficiency, or having a visual or hearing impairment will be identified by a specific code in the Group Name field on the Patient Record Report. The information is shared to help you better assist your patients.

LEP = Limited English Proficiency	LRPHI = Limited Reading Proficiency and Hearing Impaired
LRP = Limited Reading Proficiency	VIHI = Visual and Hearing Impairment
VI = Visual Impairment	LERPVI = Limited English and Reading Proficiency and Visual Impairment
HI = Hearing Impairment	LERPHI = Limited English & Reading Proficiency and Hearing Impairment
LERP = Limited English and Reading Proficiency	LRPVIHI = Limited Reading Proficiency, Visual and Hearing Impairment
LEPVI = Limited English Proficiency and Visual Impairment	LRLEPVIHI = Limited Reading & English Proficiency, Visual and Hearing Impairment
LEPHI = Limited English Proficiency and Hearing Impairment	LEPVIHI = Limited English Proficiency & VI and HI
LRPVI = Limited Reading Proficiency and Visual Impaired

Member Identification Number (OR)

CareOregon: Members are reported by an alphanumeric identification number.

Eligibility & Authorization (SC)

Members are reported by a 10-digit identification number.

BlueChoice HealthPlan coverage is shown on the VSP Patient Record Report as “VSP Elements (Advantage/Medicaid network)”

Medicaid Appointment Availability Requirements (UT)

The following access standards are required for participation in the VSP Utah Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (VA)

The following access standards are required for participation in the VSP Virginia Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 seconds to answer office phone or ability to leave a message within 45 seconds
30 minutes (maximum) wait time from scheduled appointment time
10 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Medical exam should be made within 7 days
Specialty care appointments should be made within 15 business days
Urgent care during office hours should be seen within 24 hours based on patient’s condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (WA)

The following access standards are required for participation in the VSP Washington Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Exam

Children (ages 0 - 20): Molina Healthcare members are eligible for an eye exam every 12 months.

Adults (ages 21 and over): Members are eligible for an eye exam every 24 months.

Materials Eligibility

Children (ages 0 – 20) are eligible for materials. All materials (frame, lens, contact lenses) are provided by the state’s vision hardware contractor, CI Optical. For additional information, refer to the Washington Apple Health (Medicaid) Vision Hardware Program billing guide.

For adults - eyeglass frames and lenses are not covered. You can purchase eyeglass frames and lenses through participating optical providers at a discounted price. Refer to WA State Health Care Authority for more information.

Visually Necessary Contact Lenses

Visually necessary contact lenses are covered if patients meet any of the following criteria:

A spherical correction of plus or minus 6.0 diopters or greater in at least one eye.
When contact lenses are required to correct or treat the following conditions:
Therapeutic contact bandage lenses only when needed immediately after eye injury or eye surgery.
High anisometropia (when refractive error difference between the two eyes is at least plus or minus 3.0 diopters, and eyeglasses cannot reasonably correct the refractive errors)
Aphakia
Keratoconus
Corneal softening

Member Identification Number (WV)

Members are reported by an 11-digit identification number.

(CA)

Note:

Failure to meet the training requirement may lead to removal from the VSP Medicaid Network.

Medicaid Appointment Availability Requirements (IL)

The following access standards are required for participation in the VSP Illinois Medicaid Doctor Network:

24-hr access to provide instruction on how and where to obtain services, including instructions for an after-hour emergency
For scheduled appointments, the wait time in offices should not exceed 60 minutes from appointment time, until the time seen by the provider.
Three weeks (maximum) for scheduling or rescheduling routine, preventative eye exams.
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (MI)

The following access standards are required for participation in the VSP Michigan Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 business days for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (NV)

The following access standards are required for participation in the VSP Nevada Medicaid Doctor Network:

24-hr access to provide instruction on how and where to obtain services, including instructions for an after-hour emergency
30 minute (maximum) wait time from scheduled appointment time
30 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (NH)

The following access standards are required for participation in the VSP New Hampshire Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
45 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Patient Eligibility and Services (NY)

The following clients may have coverage exceptions for specific Medicaid populations. Please make sure to check eligibility before providing services to patients as coverage can vary by client. Special handling information is available for the following clients:

Prime Health Choice

Medicaid Appointment Availability Requirements (OH)

The following access standards are required for participation in the VSP Ohio Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 calendar days for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (OR)

The following access standards are required for participation in the VSP Oregon Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
4 weeks for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Medicaid Appointment Availability Requirements (SC)

The following access standards are required for participation in the VSP South Carolina Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
45minute (maximum) wait time from the scheduled appointment time
4-6 weeks for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient’s condition
Emergent care should be directed to the appropriate emergency facility

Exam (UT)

Molina Healthcare members are eligible for an eye exam every 12 months.

Exam (VA)

Aetna Better Health Adults (21 and over): Are eligible for an exam every 12 months.

Aetna Better Health (20 and under): Are eligible for an exam every 24 months.

Magellan: Members are eligible for an exam every 24 months.

Molina, Sentara, and VA Premier: Members are eligible for an exam every 12 months.

(WA)

Note:

Bill VSP with the appropriate diagnosis codes and modifier KX for the fitting and evaluation. Visual necessity must be documented in the patient’s file.

Medicaid Appointment Availability Requirements (WV)

The following access standards are required for participation in the VSP West Virginia Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
21 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Exam (AZ)

20 and under: Members are eligible for a routine exam once every State fiscal year (October 1 to September 30).

Fundus photography with interpretation and report, is covered for children ages three through six as part of the EPSDT visit due to challenges with a child’s ability to cooperate with traditional vision screening techniques. Fundus photo screening is limited to a lifetime coverage limit of one. Bill this service with an Essential Medical Eye Care authorization.

21 and over: Members are not eligible for exams.

American Sign Language (ASL) Interpretation Services (CA)

If you or a member of your staff are ASL-fluent, you may, of course, communicate with hearing-impaired patients in that manner. If neither you nor a member of your staff have fluency in ASL, make arrangements for an ASL face-to-face interpreter to assist at no cost to the patient or to you. If you need help finding an ASL interpreter, you may contact VSP Customer Care at 800.615.1883.

Exam (IL)

Members are eligible for a routine exam once every 12 months from date of service.

Exam (MI)

Aetna Better Health members are eligible for an exam every 12 months.

Molina Healthcare (Medicaid) members are eligible for an exam every 24 months.

Molina Duals Options Michigan Health Link (MMP) members are eligible for an exam every 24 months.

Exam (NV)

Members are eligible for a routine exam once every 12 months from date of service.

Exam (NH)

Members are eligible once every 12 months.

Medicaid Appointment Availability Requirements (NY)

The following access standards are required for participation in the VSP New York Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
60 minute (maximum) wait time from scheduled appointment time
30 calendar days (maximum) for scheduling or rescheduling routine, preventative eye exams
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Exam (OH)

18 to 44: Aetna Better Health members are eligible for an exam every 12 months.

45 to 59: Aetna Better Health members are eligible for an exam every 24 months.

60 and over: Aetna Better Health members are eligible for an exam every 12 months.

Pregnant women are eligible for an exam every 12 months. Call VSP at 800.615.1883 to verify eligibility and obtain authorization.

Exam (OR)

20 and under: Eligible for exam every 12 months.

21 and over: Eligible for exam every 24 months.

Refraction

For procedure code 92015, the allowed amount is included in the reimbursement amount of the exam procedure code. See Coordination of Benefits for exceptions.

Coordination of Benefits

For patients with Medicare and Medicaid coverage:

Bill eye exams 92002, 92004, 92012, 92014 and 92015 to Medicare and bill VSP as secondary. Allowed amount for the eye refraction is $6.00

For additional information on coordination of benefits, see Submitting Claims/Billing & Reimbursement.

Exam Coverage (SC)

Members 20 and under: BlueChoice HealthPlan members are eligible for a routine exam every 12 months.

21 and over: BlueChoice HealthPlan members are eligible for a routine exam every 12 months.

Materials Eligibility (UT)

Children’s Health and Evaluation Care - CHEC (ages 0 - 20) and Pregnant Adults: members are eligible for lenses and frames every 24 months.

CHIP (ages 0 – 19): Members are not eligible.

Adults (ages 21 and over): Members are not eligible.

Frames

When medically necessary, Medicaid provides one standard frame, plastic, or metal. Frames must be reusable and if the lens prescription changes, the same frame must be used when possible. Medicaid reimburses one pair of eyeglasses every 12-month period.

If a member requires lenticular lenses, use code V2025 and modifier Lenses

Lenses covered include single vision, bifocal or trifocal, with or without slab-off or prism, in glass or plastic.

To receive reimbursement for lenses, lens must have 0.5 diopter or greater in either sphere or cylinder power in either eye.

Non-covered Services or Upgrades

With few exceptions, a provider may not bill a Medicaid member as the Medicaid payment is considered payment in full. Exceptions may include a member request for service that is not medically necessary and therefore not covered. Examples of services considered not medically necessary: more expensive frames, tinted lenses, lenses of special design. Please review the Utah Medicaid Provider Manual for conditions which must be met before billing a non-covered service or upgrade.

Copayments

CHIP (ages 0 – 19): Exam copay applied once per service period. Alaska or Native American members - $0; Plan B members - $5; Plan C members - $25

Exam Copay (VA)

Aetna Better Health, Magellan Complete Care of Virginia: FAMIS (19 and under): $0, $2 or $5 copay for routine eye exams.

The following clients have opted to offer enhanced Medicaid services to some of their Medicaid populations. Please refer to the Client Exceptions section.

Aetna Better Health Virginia DSNP
Aetna Better Health of Virginia CCC Plus (MLTSS)
Magellan Complete Care of Virginia (Adults 21 and over)
Virginia Premier DSNP
Virginia Premier MLTSS

(WA)

Note:

Order NCL contact lenses from the agency’s contractor CI Optical.

Exam (WV)

Aetna Better Health members

20 and under: Members are eligible for exam every 12 months.

21 and over: Members are eligible for an exam every 12 months.

Materials Eligibility (AZ)

Note: All procedure codes for materials dispensing must be billed with the appropriate modifier:

NU – new equipment
RA – replacement
KX – visual necessity must be documented in the patient’s file.

20 and under: Members are eligible for lenses and frames once every State fiscal year (October 1 to September 30).

21 and over: Members are not eligible for materials. However, members are covered for post-cataract services. Refer to the Post Cataract Eligibility section for complete information.

Lens materials

Use modifier NU to identify new lenses. Use RA when replacing lenses.

The following options are covered when visually necessary and documented by the treating physician:

Anti-reflective coating
High Index
Oversize lenses
Photochromatic
Polycarbonate
Progressive
Scratch resistant coating

Medicaid Appointment Availability Requirements (CA)

The following access standards are required for participation in the VSP California Medicaid Doctor Network:

24-hour access to provide instruction on how and where to obtain services
30 seconds to answer office phone or ability to leave a message within 45 seconds
30 minute (maximum) wait time from scheduled appointment time
15 business days (maximum) for scheduling or rescheduling routine, preventative eye exams
Medical exam should be made within 7 days
Specialty care appointments should be made within 15 business days
Urgent care during office hours should be seen within 24 hours based on patient condition
Emergent care should be directed to the appropriate emergency facility

Materials Eligibility (IL)

20 and under: Members are eligible for lenses and a frame once every 12 months from date of service.

21 and over: Members are eligible for lenses and a frame once every 24 months from date of service

Single Vision Lenses

Lenses are covered only if the power is at least ± 0.75 diopters, in either the sphere or cylinder component.

Bifocal Lenses

Bifocal lenses are covered only if the power of the bifocal addition is ± 1.00 diopter or more. A change in lenses is covered if the distance power meets the minimum change requirements (± 0.75 diopters), or if the power of the bifocal addition is changed by at least ± 0.50 diopters.

Lens Options

Polycarbonate lenses are covered for all members.

The following lens enhancements are covered when visually necessary:

High index lenses
Polarized lenses

Referral (MI)

If the patient requires referral to a specialist/MD, refer the patient to the client or the patient’s primary physician.

Materials Eligibility (NV)

Members are eligible for lenses and frames once every 12 months from date of service.

Lens Options

All Members:

The following lens enhancements are covered when visually necessary:

HI – Index
UV
Tints

20 and Under:

Polycarbonate – when visually necessary
Scratch coating

Materials Eligibility (NH)

Members are eligible once every 12 months.

Frame

Deluxe frames (V2025) are covered if visually necessary for Medicare members only. The claim must be submitted as a COB with Medicare. Bill as follows:

Bill V2020 on the first claim line for the cost of a standard frame.
Bill V2025 on the second claim line for the difference between the charges for a standard and deluxe frame.
Include a copy of the Medicare EOP or EOB when you submit the claim to VSP.

Exam (NY)

Centers Plan for Healthy Living, Prime Health Choice

20 and under: Members are not covered.

21 and over: Members are covered in full for an exam every 24 months.

Exception: Prime Health Members are eligible for an exam every 12months.

Materials Eligibility (OH)

18 to 44: Aetna Better Health members are eligible for lenses and frames every 12 months.

45 to 59: Aetna Better Health members are eligible for lenses and frames every 24 months.

60 and over: Aetna Better Health members are eligible for lenses and frames every 12 months.

Pregnant women are eligible for lenses and frames every 12 months. Call VSP at 800.615.1883 to verify eligibility and obtain authorization.

Lenses

Initial Lenses: Lens prescriptions must meet one of the following minimum prescription criteria:

+ 0.75 diopters for a hyperopic sphere
- 0.50 diopters for a myopic sphere
0.50 diopters cylinder
0.50 diopter imbalance
0.50 prism diopter vertical
3.00 prism diopter lateral

Subsequent Lenses

Subsequent lenses are visually necessary lenses that are provided after the initial lenses. Subsequent lenses are not replacement lenses. Please refer to the replacement section for information on replacement lenses.

Subsequent lenses must meet the lens prescription minimum requirements above and must also have a change of one of the following:

± 0.50 diopter sphere
± 0.50 diopter cylinder
10 degrees for a 1 cylinder or less
5 degrees for a 1.12 cylinder or more

Lens Options

Polycarbonate lenses are covered.
Scratch-resistant coating is covered.
Glass lenses and other lens options are only available if visually necessary.

Materials Eligibility (OR)

20 and under: Eligible for eyeglasses every 12 months.

21 and over: Eligible for eyeglasses every 24 months.

Lens options

Photochromic and Solid Tints/dyes: Photochromics (V2744) and solid tints/dyes (V2745) are only payable for patients with documented albinism and pupillary defects.

Material Coverage (SC)

20 and under: BlueChoice HealthPlan members are eligible for glasses every 12 months.

21 and over: BlueChoice HealthPlan members are eligible for glasses every 24 months (see client exception below for more details).

Lenses

Polycarbonate lenses must be provided to all members 20 years of age and younger, are covered, and must be billed with the appropriate codes. Non-polycarbonate lenses are not covered.

Visually Necessary Contact Lenses (UT)

Visually necessary contact lenses are covered for eligible members 20 and under or pregnant adults if one of the following conditions is present. Call VSP at 800.615.1883 to obtain an authorization number.

Visual acuity cannot be corrected to 20/70 in the better eye with glasses lenses.
The refractive error is greater than +- 8D.
An unusual eye disease or disorder exists which is not correctable with eye glasses.
To correct aphakia, keratoconus, nystagmus, or severe corneal distortion
Other visually necessary medical conditions which require a contact lens
Contact lenses are not covered for moderate visual improvement and/or cosmetic purposes.
Piggyback lenses are a covered benefit for patients who can’t 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 bill for both soft and rigid contact lenses in conjunction with modifier KX. In Box 19 indicate Piggyback Lenses.

Materials Eligibility (VA)

Aetna Better Health Adults (21 and over): Are eligible for a combined materials allowance every 12 months.

Aetna Better Health (20 and under): Are eligible for lenses and a frame every 24 months.

Magellan Adults (21 and over): Are eligible for a combined material allowance every 24 months.

Magellan (20 and under): Are eligible for lenses and a frame every 24 months.

Molina: Members are eligible for a combined material allowance every 12 months.

Sentara Adults (21 and over): Are eligible for a $100 frame allowance every 12 months.

Sentara (20 and under): Are eligible for a complete pair (lens and frame) every 12 months with the Elements benefit, see details below.

Virginia Premier Adults (21 and over): Are eligible for a $100 frame allowance every 12 months.

Virginia Premier (20 and under): Are eligible for a complete pair (lens and frame) every 12 months with the Elements benefit, see details below.

Lens Enhancements

Solid tints/dyes are limited to patients with certain documented medical conditions, such as albinism and/or photophobia.

(WA)

Dispensing and Materials Services

When billing for the dispensing of glasses or contact lenses, refer to the VSP Washington Medicaid Fee schedule for the appropriate fitting codes.

Dispensing can be billed with lens or frame or dispensing separate.

Back-up Eyeglasses

The patient may receive one pair of back-up eyeglasses for eligible patients who wear contact lenses as their primary visual correction aid. Limited to once every two years.

Interim Benefits

Is allowed for children for exam and/or dispensing
Interim benefits are utilized for refractive change
Are not allowed for adults
Are not related to Repair/Refitting

Repair

Member may be eligible for incidental repairs. Refer to the Washington Apple Health (Medicaid) Vision Hardware Program billing guide for coverage requirements and eligibility.

Materials Eligibility (WV)

20 and under: Members are eligible for materials every 12 months.

Photochromic lenses are covered for members with a diagnosis of albinism and pupillary defects (E70.20 - E70.9)
Ultraviolet lenses are covered for members with a diagnosis of aphakia (H27.00 - H27.03, Q12.3, Z96.1)

Eyeglass Lenses (CA)

(IL)

Note:

Bill with the appropriate codes and modifier KX. Visual necessity must be documented in the patient’s file.

Coordination of Benefits (MI)

Commercial

If a Medicaid beneficiary is enrolled in a commercial health insurance plan, the rules for coverage by the commercial health insurance must be followed. Medicaid is liable for Medicaid covered services that are not part of the commercial health insurance coverage. A response from the other insurance (e.g., Remittance Advice (RA), Explanation of Payments (EOP), Explanation of Medicare Benefits (EOMB) or a denial letter) must be obtained and submitted with the claim.

Aetna Better Health MIChild (SCHIP) members cannot be enrolled in another health plan.

Medicare

Procedure codes 92002-92014 and 92015 must be billed to Medicare prior to billing VSP.
Submit the Medicare claim to VSP with the RA, EOP, or EOMB or denial letter.
Do not use S0620 or S0621 to bill eye exams or eye refractions for Medicare patients.

For additional information regarding coordination of benefits, see Submitting Claims/Billing & Reimbursement.

(NV)

Note:

Bill with the appropriate codes and modifier KX. Visual necessity must be documented in the patient’s file.

(NH)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Materials Eligibility (NY)

Centers Plan for Healthy Living, Prime Health Choice

20 and under: Members are not covered.

21 and over: Members are covered for a pair of eyeglasses every 24 months.

Two Pair in Lieu of Bifocals

The patient may receive two pairs of single vision lenses, one for distance vision and one for near vision, in lieu of bifocal eyeglasses, if either of the following conditions exists:

For patients less than 70 years of age

Two pair of eyeglasses, instead of bifocals, may be ordered/dispensed when medically necessary, e.g., medical, physical and/or psychological condition(s) may preclude a patient from wearing a bifocal lens; previous attempts to wear bifocal lenses were unsuccessful; patient has a condition which results in frequent falls and injuries.

For patients 70 years of age or older

Enrollees who are at least 70 years of age may receive two complete pair of eyeglasses (for both distance and reading), instead of bifocal lenses.

Visual necessity must be documented in the patient’s medical record. Call VSP at 800.615.1883 for the second authorization number.

Lens Options

The materials and services listed below are covered if visually necessary.

(OH)

Frame

Only standard frames are covered (V2020).

Visually Necessary Contact Lenses

Visually necessary contact lenses are covered if one of the following conditions is present:

Anisometropia greater than or equal to 3.00 diopters
High ametropia greater than or equal to ±10.00 diopters in either eye in any meridian based on the spectacle prescription

Aphakia	H27.01 (RT), H27.02 (LT), H27.03 (BI)
Corneal dystrophies	H18.50 - H18.59
Corneal transplant	Z94.7
Keratoconus	H18.601 (RT), H18.602 (LT) , H18.603 (BI) Q13.3, Q13.4
Nystagmus	H55.00 - H55.09 H81.10 - H81.13

Piggyback lenses are a covered benefit for patients 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 bill for both soft and rigid contact lenses in conjunction with modifier KX. In Box 19 indicate Piggyback Lenses.

(OR)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(SC)

Note:

Polycarbonate single vision, bifocal, and trifocal lenses in an Otis & Piper frame include UV and scratch coating. You won’t receive a separate payment for lenses.

(UT)

Note:

If patient meets any of the above criteria, bill with appropriate diagnosis codes along with modifier KX for contact lens materials and contact lens dispensing. Visual necessity must be documented in the patient’s file.

(VA)

All plastic lenses provided to patients must have an anti-scratch coating.

Virginia Premier and Sentara (20 and under): Polycarbonate single vision, bifocal, and trifocal lenses in an Otis & Piper frame are covered and include UV and scratch coating. You won’t receive a separate payment for lenses. Refer to the Advantage Network Lens Enhancements Chart for pricing on non-covered lens enhancements and follow the guidelines below under Patient Responsibility: Non-covered Services/Materials.

Aetna Better Health of Virginia, and Aetna Better Health of Virginia FAMIS (19 and under), Magellan Complete Care of Virginia (20 and under) and Virginia Premier (diabetic members): Patients are eligible for polycarbonate lenses if they meet at least one of the benefit criteria listed below:

High power lenses (+/- 4.00 diopters in either meridian for either eye)
Monocular visual acuity (20/200 or worse in either eye)

(WA)

Note:

VSP does not cover CPT codes 92370 and 92371 (spectacle repair and refitting).

(WV)

21 and over: Members are eligible for visually necessary contact lenses every 12 months. See Visually Necessary Contact Lenses.

(AZ)

Note:

Bill with the appropriate diagnosis codes and modifier KX, including NU or RA as appropriate. Visual necessity must be documented in the patient’s file.

(CA)

Note:

All providers are instructed to use Prison Industry Authority (PIA) optical laboratories to fabricate lenses for dates of service on or after January 1, 2020.

(IL)

Frame

Standard frame – V2020 is covered

Safety frame (deluxe) – V2025 is covered when visually necessary. Bill with modifier KX and visual necessity must be documented in the patient file.

Client Exception

Health Care Services Corporation (Blue Cross Community Health Plans) 30109035, provides a frame allowance of $40 for all members. You can balance bill the patient for any amount beyond the allowance.

Materials Eligibility (MI)

Aetna Better Health members are eligible for materials every 12 months.

Molina Healthcare (Medicaid) members are eligible for materials every 24 months.

Molina Duals Options Michigan Healthlink (MMP) members are eligible for materials every 12 months.

Initial lenses

Initial lenses are defined as the first prescription lenses worn by a person regardless of how they were obtained (i.e., through Medicaid, commercial insurance or a private-pay transaction). The following minimum diopter criteria must be met:

MIChild and Members under 43:

0.50D myopia or astigmatism
0.75D anisometropia or hyperopia

Members 43 and over:

0.50D myopia, astigmatism, hyperopia or presbyopia
0.75D anisometropia

Subsequent Lenses

Members are covered for subsequent lenses -- visually necessary lenses that are provided after the initial lenses are dispensed due to a refractive change in one eye of at least:

0.75D in the meridian of greatest change;
or a change in the cylinder axis of at least 10 degrees for cylinders of 1.00D or more.

These lenses must meet the minimum diopter criteria specified above. A new exam may be requested due to a prescription change. Contact VSP to obtain authorization. Subsequent lenses are not replacement lenses. Please refer to the Replacement section for information on replacement lenses.

Two Pair In Lieu of Bifocal

Members may receive two pairs of single vision lenses, one for distance vision and one for near vision, in lieu of bifocal eyeglasses, if the patient meets either of the following instances:

The patient has clearly demonstrated the inability to adjust to bifocals.
The patient’s physical condition does not allow for bifocal usage.

Visual necessity must be documented in the patient’s medical record. Call VSP at 800.615.1883 for the second authorization number.

Providing both multi-focal and single vision eyeglasses for interchangeable usage is not covered.

Polycarbonate Lenses

Members are covered for polycarbonate lenses when the diopter criteria for initial or subsequent lenses is met.

To identify polycarbonate lenses, use one of the appropriate base lens HCPCS procedure codes listed below and add modifier U1.

V2100-V2114
V2200-V2214

High Index Lenses

Members are covered for high index lenses when the diopter criteria for initial or subsequent lenses is met. To identify high index lenses, use one of the appropriate base lens HCPCS procedure codes listed below and add modifier U2.

V2102, V2111, V2112, V2113, V2114, V2202, V2211, V2212, V2213, V2214

Modifier	Description	Special Instructions
U1	Polycarbonate lenses	Determines payment rate.*
U2	High index lenses	Determines payment rate.*

*V2782 and V2784 will not be reimbursed separately.

Frame

A frame is a covered benefit for members at no cost.

Dispensing Services

Dispensing services are a Medicaid benefit and do not require PA. Vision providers may bill a dispensing fee for dispensing prescription lenses, prescription lenses with frames, or replacing a complete frame.

Reimbursement for the dispensing service includes the vision provider’s services in selecting, ordering, verifying, and aligning/fitting of eyeglasses as described above. Routine follow-up and post-prescription visits (e.g., for minor adjustments) are considered part of the dispensing service and are not separately reimbursable.

Safety Frame

Members are covered for safety frames, in addition to regular eyeglasses. These frames correspond to ANSI Z87.1-2003 standards.

Polycarbonate lenses of a minimum two-millimeter thickness must be inserted in a safety frame marked “Z 87” or “Z 87-2.”

To identify polycarbonate lenses, use one of the appropriate base lens HCPCS procedure codes listed below and add modifier U1.

V2100-V2114
V2200-V2214

(NV)

Frame

Existing frames must be used whenever possible. If a new frame is necessary, metal or plastic can be used, according to the patient’s preference, up to the allowed amount. Providers must stock a variety of frames to enable the recipient to choose a frame at no cost to them, if they so choose.

If the recipient selects a frame greater than VSP’s Medicaid allowable, they will be responsible for the additional amount.

The recipient’s agreement to make payment must be in writing. A copy of the agreement must be retained in the recipient’s chart. The Nevada Medicaid Surveillance and Utilization Review Unit (SUR) conducts a regular review of claims history to monitor this.

21 and Over: Retail frame allowance alternates between $170 and $70 each service year. Verify Patient Record Report for frame allowance. Member may be balanced billed frame overages.

Frame Case

One frame case must be provided to the patient as it is a covered material and included in the frame reimbursement.

Lenses

The refractive error is at least plus or

minus .50 diopter according to the type of refractive error, in each eye.

Two Pair in Lieu of Bifocals

Well Sense members may receive one pair of glasses with bifocal corrective lenses or two pairs of eyeglasses, one for close vision and one for distance vision, instead of one pair with bifocal corrective lenses.

Patient must have a refractive error of at least ±0.50 diopter for both near and distance vision and the must meet one of the following criteria:

Cannot wear bifocal satisfactorily
Patient currently has two pairs of eyeglasses
There is a safety concern.

Visual necessity must be documented in the patient’s file. Call VSP at 800.615.1883 for the second authorization number.

Trifocal Lens

Trifocal lenses are covered based on specific educational or employment performance needs, or if the patient currently wears trifocals.

(NY)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(OH)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(OR)

Scratch coating: Scratch coating is a covered benefit. The reimbursement is included in the reimbursement of the base lens and additional payment will not be made for the scratch coating. See Patient Responsibility.

High Index: Patient must meet the following criteria:

Power is +/- 10 or greater in any meridian in either eye; or
Prism diopters are +10 diopters in either lens.

(SC)

Lens Enhancements

If visually necessary, the following lens enhancements are covered for patients 20 years of age and younger only.

Low Vision (UT)

Low vision aids (V2600) are covered for eligible CHEC members 20 and under or adult members who are pregnant.

(VA)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(WA)

Replacement

If the patient has a prescription change requiring an interim exam, please call VSP at 800.615.1883 for an authorization number. When billing for the dispensing of glasses or contact lenses, refer to the VSP Washington Medicaid Fee schedule for the appropriate fitting codes. Document the reason for replacement in the patient’s file.

Timely Filing

File claims within 365 days of the date of service to ensure compliance with Washington Medicaid guidelines. Claims that are not filed within this timeframe may be denied.

Vision Therapy

Vision Therapy is covered for children and adults, if visually necessary. Issue an authorization under Vision Therapy. Bill exam services (92060) and/or vision therapy sessions (92065) with appropriate diagnosis code(s), along with modifier KX. Visual necessity must be documented in the patient’s medical record.

Low Vision

Low Vision is covered for children and adults, fittings only, if visually necessary. Bill fitting services (92354, 92355) with appropriate diagnosis code(s), along with modifier KX. Visual necessity must be documented in the patient’s medical record.

Refer to the Low Vision Coverage page on the Provider Reference Manual.

Patient Responsibility

Covered Services/Materials

Visually Necessary Contact Lenses (WV)

The fitting, adjusting, and dispensing of contact lenses are included in the payment of the lenses.

20 and under:

Refractive error which is 9 diopters or greater in any meridian;
Keratoconus
Anisometropia when the difference in power between 2 eyes is 3 diopters or greater
Anisekonia
Aphakia

21 and over:

Aphakia
Keratoconus

(AZ)

Frame

Only standard frames are covered (V2020). Use modifier NU to identify new frame. Use RA when replacing frame.

(CA)

Single Vision Lenses

Single vision lenses must meet at least one of the following requirements:

Minimum Rx of ±0.75D in at least one meridian of either eye.
Astigmatic correction of 0.75D or more of either eye.
Total differential prismatic correction in the vertical prism of 0.75D or more.
Total differential prismatic correction in the horizontal prism of 0.75D or more.
Power in any meridian that differs from the corresponding meridian of the lens for the other eye by 0.75D or more.

Multifocal Lenses

Multifocal lenses must have an add power of at least 0.75 diopters in the reading segment. Bifocal lenses are covered if the near add power is at least 0.75 diopters greater than the prescription in the distance portion of the lens. The distance part of a bifocal lens has no qualifying criteria.

Trifocal lenses that meet the criteria for single vision, multifocal and replacement lenses are covered only for recipients who currently wear trifocals. Trifocal lenses for first-time wearers are not a Medi-Cal benefit.

Visually Necessary Contact Lenses (IL)

Visually necessary contact lenses are covered if one of the following conditions is present:

Aniridia
Aphakia
Corneal Transplant
Corneal Dystrophies
Keratoconus
Nystagmus
Anisometropia: 3.00 or more diopter difference in prescription between the two eyes
High Ametropia: greater than or equal to +/- 10.00 diopters in either eye
Physical condition of ears or nose which prohibits use of eyeglasses

For additional information on conditions that qualify for visually necessary contact lenses please refer to the Contact Lens Benefit section of VSP Provider Reference Manual.

(MI)

Note:

Do not bill the U1 modifier with HCPCS procedure code S0581.

Visually Necessary Contact Lenses (NV)

Visually necessary contact lenses are covered if visually necessary. When submitting a claim for piggyback lenses, you must bill with all appropriate codes and provide the following information in Box 19: Piggyback lenses.

(NH)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(NY)

Polycarbonate lenses (21 and over)
Tints

High index lenses

Patient must be monocular with functional vision in only one eye, or have a history of auto aggressive behavior with a history of breaking glasses.
Tints are covered if the patient has photophobia.
Only covered for 10D or greater

Visually Necessary Contact Lenses and Fitting/Dispensing

Materials, fitting and dispensing require a KX modifier.

Low Vision (OH)

Low vision aids and fitting of low vision aids are covered if visually necessary. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s). Low Vision exams are not covered.

(OR)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(SC)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(UT)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(VA)

Frame

Virginia Premier and Sentara (20 and under): Members must select a frame from the Otis & Piper Eyewear Collection. These frames are lab-supplied through VSPOne™ Columbus.

Deluxe frame: If the patient has an unusual circumstance or visual need that prevents them from selecting any of the existing covered frames; use V2025 to bill for the deluxe frame.

Patient supplied frame: Not allowed.

(WA)

Note:

It’s the doctor’s responsibility to verify the eligibility status of each patient at the time of service and obtain the appropriate authorization. Failure to obtain authorization doesn’t create a payment liability for the patient.

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(WV)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(CA)

Note:

In addition to the appropriate HCPCS code, bill modifier KX and RA for trifocal lenses.

(IL)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(MI)

Note:

Bill with appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(NV)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(NH)

Miscellaneous Vision Services

Reimbursement for scratch coating is included in the cost of the base lens.

Visually Necessary Contact Lenses

Visually necessary contact lenses are covered if patients meet any of the following criteria:

Ocular pathology in cases where the visual acuity is not correctable to 20/70 or better
When contact lenses are required to correct aphakia or to treat corneal diseases.

(NY)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(OH)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(OR)

Polycarbonate lenses: Patient must meet at least one of the benefit criteria listed below.

Children ages 0-20
Patients with developmental disabilities
Patients who are blind in one eye and need protection for the other eye, regardless of whether a vision correction is required

(SC)

Anti-reflective coating
High index when power is ±10 or greater in any meridian in either eye; or prism is +10 diopters in either lens.
Mirror coating
Oversize
Photochromic
Polarized
Scratch-resistant coating
Tints
UV lens

If not visually necessary, refer to the Advantage Network Lens Enhancements Chart for pricing and follow the guidelines below under Patient Responsibility: Non-covered Services/Materials.

Frames

The only covered frames are those in the Otis & Piper Eyewear Collection. These frames are lab-supplied through VSPOne™ Columbus.

Deluxe frame: A non-Otis & Piper frame may be selected if visual/medical necessity is established.

Patient supplied frame: Not allowed.

Vision Therapy (UT)

Vision therapy exam is covered for CHEC members 20 and under and those adult members who are pregnant if visually necessary. Orthoptic and/or pleoptic training is not covered. Bill exam services (92060) with appropriate diagnosis codes along with modifier KX. Visual necessity must be documented in the patient’s medical record. Issue an authorization under Vision Therapy.

(VA)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(WA)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all the following requirements are met. For exceptions, please refer to Covered Services section above.

Refer to the Washington Apple Health Vision Hardware Program billing guide for material coverage criteria and exceptions.
The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material.
You may request that the patient or guardian sign an Agreement of Financial Responsibility that clearly states that the patient is aware they are choosing to purchase non-covered services or materials. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

Vision Therapy (WV)

Orthoptics Training is only covered for children under age 10 years for treatment of strabismus and other disorders of binocular eye movements. Therapy is limited to a total of 6 sessions per calendar year. Issue an authorization under Vision Therapy.

Sensorimotor examinations (92060) and/or vision therapy sessions (92065).

WV CHIP

Medical necessity review is required beyond 20 visits for corrective eye exercise therapy. Maintenance therapy is not a covered benefit by WVCHIP.

The initial twenty VT visits do not require prior authorization but must be for a condition that affects binocular vision, including convergence insufficiency disorders.

Visually Necessary Contact Lenses (AZ)

Visually necessary contact lenses are covered if visually necessary. Use modifier NU to identify new lenses. Use RA when replacing lenses. When submitting a claim for piggyback lenses, you must bill with all appropriate codes and provide the following information in Box 19: Piggyback lenses.

(CA)

Two Pairs in Lieu of Bifocals

Two pairs of single vision eyeglasses, one for near vision and one for distance vision, are covered in lieu of multifocal eyeglasses only when one of the following conditions exists:

There is evidence that a recipient cannot wear bifocal lenses satisfactorily due to non-adaptation or a safety concern (conditions specified below).
A recipient currently uses two pairs of such eyeglasses and does not use multifocal eyeglasses.

Lenses must be fabricated at PIA lab. PIA will review the prescription requirements, and if approved fabricate the lenses.

When billing two pairs of single vision eyeglasses frames in lieu of bifocals for recipients 38 years of age and older who meet the conditions specified in the California Department of Health Care Services Vision Care Provider Manual:

(IL)

Client Exceptions

For Health Care Services Corporation (Blue Cross Community Health Plans) members, when visual necessity is identified but does not meet the criteria listed, you may contact VSP to request specific benefit review for your patient prior to rendering services. Specific benefits available for review include necessary contact lenses.

Patient Responsibility (MI)

Covered Services/Materials

(NV)

When glasses to be worn over contact lenses are visually necessary, call VSP at 800.615.1883 to request the spectacle lenses and frame authorization number at the same time or within 30 days of the contact lens claim submission date. For patients with keratoconus, request an authorization number for spectacle lenses to be worn over contact lenses within 12 months of the contact lens claim submission date. Please have the relevant criteria information available when calling. Visual necessity must be documented in the patient’s file.

(NH)

Note: Bill with the appropriate diagnosis codes and modifier KX for the visually necessary contact lens fitting/dispensing, and visually necessary contact lenses. Visual necessity must be documented in the patient’s file.

Low Vision (NY)

Low vision evaluations, low vision aids, and fitting of low vision aids are covered if visually necessary. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s).

Exam Services

To report low vision evaluations, use CPT codes 92002-92014.

Low Vision Aids

All acceptable types of low vision aids including microscopes and telescopes must be utilized in selecting an appropriate low vision aid. Please submit a manufacturer’s invoice.

Vision Therapy (OH)

Vision Therapy exams (92060) and Vision Therapy training (92065) are covered. Call VSP at 800.615.1883 to obtain an authorization number for Vision Therapy claim(s).

(OR)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(SC)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Patient Responsibility (UT)

Covered Services/Materials

(VA)

Aetna Better Health of Virginia, Aetna Better Health of Virginia FAMIS (19 and under), Magellan Complete Care of Virginia (20 and under): Frames are covered according to the VSP Virginia Medicaid Plan Professional Fee Schedule.

Frame Case

One frame case must be provided to the patient as it is a covered material and included in the frame reimbursement.

Virginia Premier and Sentara (20 and under): VSPOne Columbus will supply a frame case for Otis & Piper frames. If a non-Otis & Piper frame is selected, a frame case must be provided. It is a covered item and included in the frame reimbursement.

Lab

Elements orders must be sent to VSPOne Columbus.

Redos

Otis & Piper orders must be returned to VSPOne Columbus. Contact the lab at 800.251.5150 for additional information.

If you need to return a defective Otis & Piper frame, contact the lab for return instructions. If a patient wants to change a frame, the lab will do a one-time redo at no charge.

Redos due to lab error

Within 60 days, redos will be expedited and redone at no cost. Call VSPOne Columbus at 800.251.5150 with any questions.

Redos due to doctor or staff error

You’ll be charged $10 for redos due to doctor or staff error within 60 days. Do not charge the patient for the redo. Call VSPOne Columbus for complete details.

Redos due to prescription changes

Lens redos due to prescription changes within 60 days are a private transaction between your practice, the patient, and the lab. VSPOne Columbus will complete a redo for $10 or you may use another lab of your choice on a private basis.

Do not send the order back to the lab. Lab will redo lenses and send them to you so you can replace old lenses.

Elective Contact Lenses

Members are not covered for elective contact lenses; exceptions are noted below. Verify ECL eligibility and allowance on patient record report.

Aetna Better Health CCC Plus 30077004 – Members 20 and under, are eligible for $100 elective contact lens allowance for both fitting and evaluation and contact materials. Balance bill the patient for any amount over the allowance. Members 21 and over, are eligible for $250 elective contact lens allowance for both fitting and materials.

Aetna Better Health 30083950 – Members are eligible for $250 elective contact lens allowance for both fitting and evaluation and contact materials. Balance bill the patient for any amount over the allowance.

Magellan Complete Care of Virginia 30083948 FAMIS 19 and under – members are eligible for $100 elective contact lens allowance for both fitting and evaluation and contact materials. Balance bill the patient for any amount over the allowance. Members 21 and over are eligible for $150 elective contact lens allowance for both fitting and materials.

If entire elective contact lens allowance isn’t used at the initial visit, the remaining allowance cannot be used at a later date. You can balance bill the patient for any amount beyond the allowance. For details, see the Patient Responsibility section below.

Visually Necessary Contact Lenses

Client Exceptions (WA)

Community Health Plan of WA (40150354) – Adult Coverage

Lenses

Single vision, bifocal, trifocal, or lenticular lenses in plastic or glass are covered. You’ll receive your Advantage Plan lens dispensing fee for covered lenses. Single Vision Lenses $16.00 Bifocal Lenses $21.00 Trifocal Lenses $35.00. If a patient selects a non-covered lens enhancement, charge the patient according to the Advantage Network Lens Enhancement Chart.

Frames

Expanded coverage for adult members includes fully covered frames from the Genesis Collection by Altair^®. Genesis frame kits are for display only as frames are lab supplied through VSPOne™ Columbus. You’ll receive a $19 frame dispensing fee. Genesis frames are fully covered for the patient when a complete pair of prescription glasses (lenses and frame) is ordered. Genesis frame only orders would be a private transaction, and the frame will not be covered by VSP. In-office finishing equipment or stock lenses may not be used.

A patient has the option of supplying their own frame or purchasing a non-Genesis frame. There is no allowance toward non-Genesis frames. Non-Genesis frame purchases would be a private transaction, and the frame will not be covered by VSP. Regardless of the frame brand that’s purchased, the benefit for lenses will still follow Advantage Plan pricing and orders must be submitted to VSPOne™ Columbus. In-office finishing equipment or stock lenses may not be used.

If you have questions about the Genesis Collection, and to request a frame kit if you don’t already have it, please call Altair Sales at 800.505.5557. To preview the product online, please visit https:// www.altaireyewear.com/brands/genesis/.

Lab

All orders must be fulfilled at VSPOne™ Columbus. This includes patient supplied frames, out-of-kit frames and Genesis frames. Genesis frames must be lab supplied.

Only in an emergency situation may a private lab be used. See Using Non-Contract Labs for more information. If a non-contract lab is used for an emergency situation, the frame purchase would be a private transaction.

Molina Healthcare 30084744 – Essential Medical Eye Care Services

Patient Responsibility (WV)

Covered Services/Materials

NOTE: It’s the doctor’s responsibility to verify the eligibility status of each member at the time of service and obtain the appropriate authorization. Failure to obtain authorization doesn’t create a payment liability for the patient.

WV CHIP Details

Covered benefits include annual exams and eyewear. Lenses/frames or contacts are limited to a maximum benefit of $125 per year. The year starts on the date of service. The office visit and examination are covered in addition to the $125 eyewear limit. Families are responsible to pay the difference between the total charge for eyewear and the $125 allowance for lenses and frames.

(AZ)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(CA)

Primary diagnosis

Presbyopia

H52.4

Secondary diagnosis

Unspecified subjective visual disturbances	H53.10
Visual discomfort	H53.141 – H53.149
Visual distortions of shape and size	H53.15
Psychophysical visual disturbances	H53.16
Other subjective visual disturbances	H53.19
Other visual disturbances	H53.8
Unspecified visual disturbance	H53.9

Low Vision (IL)

Fitting and aid for low vision is covered if visually necessary. Call VSP at 800.615.1883 to obtain an authorization number for low vision claim(s).

Low Vision Aids

Essential low vision devices are covered. Low vision corrective devices must include information explaining in detail the patient's need for the device. Please submit a manufacturer’s invoice.

(MI)

Note:

Low Vision (NV)

Low vision aids, and fitting of low vision are covered, if visually necessary. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s).

Low Vision Aids

Only basic and essential low vision aids are a benefit. Please submit a manufacturer’s invoice.

(NH)

Vision Therapy

A vision therapy exam (92060) is covered. Call VSP at 800.615.1883 to obtain an authorization number for Vision Therapy claim(s). Orthoptic training (92065) are non-covered services.

(NY)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Coordination of Benefits (OH)

If the patient has other vision coverage, coordinate benefits and bill the other carrier. Medicaid is the payor of last resort.

Refraction

92015 is the Medicaid-covered component of a comprehensive eye exam provided to a Medicaid and Medicare-covered consumer in conjunction with other Medicare covered eye exam procedures. It is reimbursed as a separate and distinct service by Medicaid when Medicare payment for an eye exam does not include payment for the refraction services component of the exam.

For additional information on coordination of benefits, see Submitting Claims/Billing & Reimbursement.

(OR)

Plano or Non-prescription Lenses

Plano or non-prescription lenses are limited to patients with one eye requiring no correction and with blindness in the other eye. The purpose of this exception is to offer protection to the remaining functional eye.

Frame Options

Deluxe frame: If the patient has an unusual circumstance or visual needs that prevent the patient from selecting any of the existing covered frames, use V2025 to bill for the deluxe frame. See Patient Responsibility.

(SC)

Frame Case

VSPOne Columbus will supply a frame case for Otis & Piper frames. If a non-Otis & Piper frame is selected, a frame case must be provided. It is a covered item and included in the frame reimbursement.

(UT)

Note:

It’s the doctor’s responsibility to verify the eligibility status of each patient at the time of service and obtain the appropriate authorization. Failure to obtain authorization doesn’t create a payment liability for the patient. You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(VA)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Essential Medical Eye Care (WA)

Essential Medical Eye Care provides medical eye care coverage for the detection, treatment and management of ocular and/or systemic conditions that produce ocular or visual symptoms. Members can see their VSP doctor when such a condition is suspected.

The following medical eye care services should be billed to VSP. For a complete list of covered services and billable diagnosis codes, please refer to Essential Medical Eye Care Plan in the Provider Reference Manual.

If your patient needs additional treatment, not covered by VSP and you’re not contracted with Molina Healthcare of Washington, please refer the patient to an appropriate physician within Molina Healthcare of Washington’s network.

Essential Medical Eye Care

(WV)

Note:

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(CA)

Lens Options

Polycarbonate lenses (V2784) are fabricated at the PIA optical laboratories without a Treatment Authorization Request (TAR) for recipients younger than 18 years of age, and for recipients 18 years of age or older who meet the following criteria of visual impairment in one or both eyes.

Visual impairment is defined as visual acuity with optimal correction equal to or poorer than 0.30 decimal notation or 20/60 Snellen, or equivalent at specified distances, or when either visual field is limited to ten degrees or less from the point of fixation in any direction.

Because polycarbonate lenses are fabricated at the PIA optical laboratories for Medi-Cal recipients who meet the above criteria, dispensing optical providers (optometrists, ophthalmologists and dispensing opticians) should bill only lens dispensing fees (CPT codes 92340, 92341, 92342, 92352 or 92353). HCPCS code V2784 (lens, polycarbonate or equal, any index, per lens) should not be billed in addition to the lens dispensing fees in this case.

Progressive lenses (V2781) requests must be submitted on the 50-3 TAR form with supporting medical justification.

Balance lens (V2700) is covered when the corrected visual acuity in the poorer eye is 0.10 diopters or more.

Slab off prism, glass or plastic, per lens (V2710) is covered with the following diagnosis codes:

Anisometropia	H52.31
Aniseikonia	H52.32

Tints V2744 (tint, photochromatic), V2745 (addition to lens, tint, any color, solid, gradient or equal, excludes photochromatic, any lens material) or V2755 (UV lens) are covered for the following conditions and diagnosis codes:

Eye pathology aggravated by exposure to light is present.
The normal eye protective system that guards against light is impaired.
Chronic pathological conditions intensified by exposure to light energy are present.

(IL)

(MI)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your U&C fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to the Covered Services section above.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material.
The patient or guardian must sign an Agreement of Financial Responsibility Form that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

Missed Appointments

Medicaid patients may not be billed for missed appointments.

(NV)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Patient Responsibility (NH)

Covered Services/Materials

Vision Therapy (NY)

Exam services (92060) and training sessions (92065) are allowed for six months only. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s).

At the end of the six-month training period, if it is necessary to extend training sessions, call VSP for an authorization. Detail the progress made, the anticipated treatment plan, and the prognosis in the patient’s medical record.

Patient Responsibility (OH)

Covered Services/Materials

(OR)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Redos (SC)

Orders must be returned to VSPOne Columbus. Contact the lab at 800.251.5150 for additional information.

If you need to return a defective Otis & Piper frame, contact the lab for return instructions. If a patient wants to change a frame, the lab will do a one-time redo at no charge.

Redos due to lab error

Within 60 days, redos will be expedited and redone at no cost. Call VSPOne Columbus at 800.251.5150 with any questions.

Redos due to doctor or staff error

You’ll be charged $10 for redos due to doctor or staff error within 60 days. Do not charge the patient for the redo. Call VSPOne Columbus for complete details.

Redos due to prescription changes

Do not send the order back to the lab. The lab will redo lenses and send them to you so you can replace the old lenses.

(UT)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section above.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material.
You may request that the patient or guardian sign an Agreement of Financial Responsibility that clearly states that the patient is aware they are choosing to purchase non-covered services or materials. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

(VA)

When submitting a claim for piggyback lenses, you must bill with all appropriate codes and provide the following information in Box 19: Piggyback lenses.

Glasses to wear over contact benefits

Spectacle lenses with frame to wear over visually necessary contacts are covered with one of the following conditions:

Aphakia
Presbyopia
Accommodative disorder
Binocular function disorder
Different prism requirements for distance and near vision

A prescription is required for the lenses. When glasses are visually necessary to wear over contact lenses, call VSP at 800.615.1883 to request the spectacle lenses and frame authorization number at the same time or within 30 days of the contact lens claim submission date. For patients with keratoconus, request an authorization number for spectacle lenses and frame to be worn over contact lenses within 12 months of the contact lens claim submission date. Please have the relevant criteria information available when calling. Visual necessity must be documented in the patient’s file.

H27.01 - H27.03 or Q12.3
High ametropia - 10.00 diopters or greater

(WV)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility form or equivalent that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

Missed Appointments

Medicaid members may not be billed for missed appointments.

(AZ)

Note:

Bill with the appropriate diagnosis codes and modifier KX, including NU or RA as appropriate. Visual necessity must be documented in the patient’s file.

(CA)

Anomalies of pupillary function and ocular pain	H57.00 – H57.9
Anophthalmos, microphthalmos and macrophthalmos	Q11.0 – Q11.3
Aphakia and dislocation of lens	H27.00 – H27.9
Autistic disorder	F84.0
Basal cell carcinoma of skin of unspecified eyelid, including canthus	C44.121 - C44.129
Benign neoplasm	D31.40 - D31.42
Benign neoplasm of unspecified part	D31.90 - D31.92
Blepharitis	H01.001 – H01.029
Blindness and low vision	H54.0X – H54.8
Burn and corrosion confined to eye and adnexa	T26.00XA - T26.92XS
Carcinoma in situ of skin of eyelid, including canthus	D04.10 – D04.12
Cataract	H25.011 – H26.9
Chorioretinal inflammation	H30.001 – H30.93
Congenital malformations of anterior segment of eye	Q13.0 – Q13.9
Congenital malformations of posterior segment of eye	Q14.0 – Q14.9
Corneal scars and opacities	H17.00 – H17.9
Diabetes	E10.10 - E13.9
Disorders of accommodation	H52.511 – H52.539
Disorders of optic [2nd] nerve and visual pathways	H47.011 – H47.9
Disorders of the globe	H44.001 – H44.9
Disorders of vitreous body	H43.00 – H43.9
Dry eye syndrome	H04.121 – H04.129
Entropion	H02.001 – H02.149
Epilepsy and recurrent seizures	G40 – G40.91
Foreign body on external eye	T15.00XA - T15.92XS
Glaucoma	H40.001 – H40.9
Herpesviral ocular disease	B00.50 - B00.59
Histoplasmosis capsulati, unspecified	B39.4
Histoplasmosis duboisii	B39.5
Injury of eye and orbit	S05.00XA - S05.92XS
Iridocyclitis	H20.00 – H20.9
Keratitis	H16.001 – H16.9
Lagophthalmos	H02.201 – H02.239
Long term (current) drug therapy	Z79
Malignant melanoma of unspecified eyelid, including canthus	C43.10 - C43.12
Malignant neoplasm of eye and adnexa	C69.00 – C69.92
Melanocytic nevi	D22.10 - D22.12
Melanoma in situ of unspecified eyelid, including canthus	D03.10 - D03.12
Migraine	G43.0 – G43.91
Multiple sclerosis	G35
Nystagmus and other irregular eye movements	H55.00 – H55.89
Other benign neoplasm of skin, including canthus	D23.10 - D23.12
Other disturbances of aromatic amino-acid metabolism	E70.20 - E70.9
Other specified malignant neoplasm of skin of unspecified eyelid, including canthus	C44.191 - C44.199
Parkinson’s disease	G20
Phakomatoses	Q85.00 – Q85.9
Pinguecula	H11.151 – H11.159
Presence of intraocular lens	V43.1
Pterygium of eye	H11.001 – H11.069
Retinal detachments and defects	H33.001 – H33.8
Retinal disorders	H35.011 – H35.9
Sarcoidosis	D86.0 - D86.9
Scleritis	H15.001 – H15.9
Secondary Parkinson’s disease	G21.0 – G21.9
Systemic lupus erythematosus	M32.0 – M32.9
Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm	E05.01
Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm	E05.00
Unspecified malignant neoplasm of skin of left eyelid, including canthus	C44.111 - C44.119
Visual field defects	H53.40 – H53.489

Occluder lens, per lens (V2770) is covered with the following diagnosis codes:

Blindness and low vision

H54.0 – H54.52A2

Vision Therapy (IL)

Vision therapy is covered. Bill exam services (92060) and/or vision therapy sessions (92065) with the appropriate diagnosis code(s). Bill vision therapy services with a separate Vision Therapy authorization.

Repair (MI)

Authorization is required; please call VSP at 800.615.1883 for an authorization number.

The following frame repairs are not a covered benefit and cannot be billed to VSP or the patient:

Aligning temples
Insertion of screws
Adjusting frames

Coordination of Benefits (NV)

If the member has vision care coverage through another carrier(s), please bill the other carrier(s) first. Once you have received the Explanation of Benefits (EOB), the Remittance Advice or denial letter from the primary insurance, please submit a copy of the documentation along with the claim to VSP. Medicaid is the payer of last resort.

(NH)

Note:

Patient Responsibility (NY)

Covered Services/Materials

(OH)

Note:

(OR)

Frame Case

One frame case must be provided to the patient as it is a covered material and included in the frame reimbursement.

Visually Necessary Contact Lenses and Fitting/Dispensing

Client Exceptions (SC)

Healthy Blue – BlueChoice HealthPlan of South Carolina expanded coverage for adults (21 and over).

Lenses

Single vision, bifocal, trifocal, or lenticular lenses in plastic or glass are covered. You’ll receive your Advantage Plan lens dispensing fee for covered lenses. If a patient chooses to add lens enhancements, charge them according to the Advantage Network Lens Enhancement Chart.

Frames

Expanded coverage for adult members includes fully covered frames from the Genesis Collection by Altair^®. Frames are lab supplied though VSPOne™ Columbus. You’ll receive a $19 frame dispensing fee. Genesis frames are fully covered when a complete pair of prescription glasses (lenses and frame) is ordered. Genesis frame only orders would be a private transaction, and the frame will not be covered by VSP. In-office finishing equipment or stock lenses may not be used.

A patient has the option of supplying their own frame or purchasing a non-Genesis frame. The non-Genesis retail frame allowance is $50. We’ll pay you up to 55% of the patient’s retail frame allowance. When the frame exceeds the retail allowance, charge the patient 80% of the retail price exceeding the allowance. Regardless of the frame brand that’s purchased, the benefit for lenses will still follow Advantage Plan pricing and orders must be submitted to VSPOne™ Columbus. In-office finishing equipment or stock lenses may not be used.

Questions about the Genesis Collection? Call Altair Sales at 800.505.5557.

Repair (UT)

Repair is allowed once every 12 months; however, Medicaid does not cover repairs due to member neglect or abuse.

Vision Therapy (VA)

Vision Therapy Exam (92060): The first vision therapy eye exam is covered for visual necessity. If more than one exam is required, the service requires written documentation supporting the additional need. Call VSP at 800.615.1883 to obtain an authorization number for Vision Therapy claim(s). Bill 92060 with appropriate diagnosis codes.

Repair (WV)

20 and under: Members are covered for repair. The repair must be cost-efficient and not exceed the cost of new eyeglasses (e.g., lenses or frames are damaged, scratched or bent but may be repaired and refitted instead of replaced). Authorization is required; please call VSP at 800.615.1883 for an authorization number. Document repairs in the patient's medical record.

21 and over: Repair is not covered.

(AZ)

Frames

Only standard frames are covered (V2020).

(CA)

Note:

For coverage information on additional miscellaneous lens items (V2700 – V2799), please refer to the California Department of Health Care Services Vision Care Provider Manual or contact Prison Industry Authority optical laboratory.

(IL)

Note:

Bill with the appropriate vision therapy diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Replacement (MI)

Authorization is required; call VSP at 800.615.1883 for an authorization number.

Frequency

Aetna Better Health and Molina Healthcare members (20 and under): No more than two pairs of replacement eyeglasses per year if replacement is due to loss, materials broken beyond repair or theft. Visual necessity must be documented in the patient's medical record.

Aetna Better Health members and Molina Healthcare (21 and over): One pair of replacement eyeglasses per year if replacement is due to loss, materials broken beyond repair or theft. Visual necessity must be documented in the patient's medical record.

Criteria for Replacement

Complete pair of glasses: When ordering a complete pair of eyeglasses, due to loss, materials broken beyond repair or theft, the replacement eyeglasses must be identical to the previously issued Medicaid eyeglasses.
Lenses Only: Replacement of corrective lenses without a frame, due to damage or breakage, is a benefit only if the replacement lenses are covered by Medicaid and the replacement limits have not been exceeded. Replacement lenses must be an identical copy of the damaged or broken lenses.
Frames Only: Replacement of a complete frame (front and temple) is a benefit only when the original frame is broken beyond repair, the prescription lenses remain usable and the replacement limits have not been exceeded. The replacement frame must be identical to the previously issued frame. If an identical frame is not available, the patient must select a frame that is covered by Medicaid. If a previously used frame (acquired before eligibility for Medicaid) requires lenses that are not a benefit (e.g., oversize lenses), a complete pair of eyeglasses that are covered by Medicaid must be ordered.
Contact Lens: Replacement of contact lenses is a benefit only if the replacement contact lenses are covered by Medicaid and the replacement limits have not been exceeded. Replacement contact lenses must be visually necessary.

Aetna Better Health and Molina Healthcare members (20 and under): Two replacements are allowed for each eye per year from the date of order of the initial or subsequent visually necessary contacts.

Aetna Better Health and Molina Healthcare members (21 and over): One replacement is allowed for each eye per year from the date of order of the initial or subsequent visually necessary contacts.

Patient Responsibility (NV)

Covered Services/Materials

(NH)

Note:

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(NY)

Note:

It’s the doctor’s responsibility to verify the eligibility status of each patient at the time of service and obtain the appropriate authorization. Failure to obtain authorization does not create a payment liability for the patient. You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(OH)

Patient Responsibility (OR)

Covered Services/Materials

The doctor must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services or materials.

Scratch coating: The cost of scratch coating is included in the reimbursement of the base lens. The patient cannot be billed for the cost of the scratch coating.
Deluxe Frame: If a specialty frame (V2025) is required, the patient can’t be billed the difference between the VSP allowed amount and your usual and customary charge.

Non-Covered Services/Materials

Lab (SC)

Orders must be sent to VSPOne Columbus.

Only in an emergency situation may a private lab be used. See Using Non-Contract Labs for more information. If a non-contract lab is used for an emergency situation, the non-Genesis frame allowance would apply.

Replacement (UT)

Frame and Lens

Replacement frames and/or lenses are allowed once every 12-months. Authorization is required to replace frames if sooner than 24 months. If necessary, an eye exam may be done when glasses are lost or broken. If the lenses need replacing, the provider must use existing frame.

Call VSP at 800.615.1883 to obtain an authorization number for the needed services. Bill with appropriate diagnosis codes along with modifier KX. Visual necessity must be documented in the patient’s file.

(VA)

Note:

All vision therapy exams should be billed with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Replacement (WV)

20 and under: Members are covered for replacement. Authorization is required. Replacement of lens is based on the following criteria:

Vertical prism change of 1 prism diopter or greater;
Horizontal prism change of 3 prism diopter or greater;
A change of .50 in the spherical equivalent of the member’s prescription;
A change of the cylinder axis of at least: 10 degrees for under 1.00D cylinder, 5 degrees for 1.00D to 2.00D cylinder or 2 l/2 degrees for 2.25D cylinder or greater;
Any change which gives at least 1 line improvement on the standard vision acuity chart;
Breakage or loss of lens; or
Change in specific eye conditions.

Replacement of frames is covered when the frames can no longer be used (e.g., broken) and repair costs exceed replacement costs. Frames must have a limited warranty. A limited warranty must be utilized for frame replacement/repair when the warranty is applicable and cost effective.

21 and over: Replacement is not covered.

Low Vision (AZ)

20 and under: Low vision evaluations, low vision aids, and fitting of low vision are covered, if visually necessary. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s).

Exam Services

To report low vision evaluations of low vision aids, use CPT code 92499.

Low Vision Aids

Only basic and essential low vision aids are a benefit. Please submit a manufacturer’s invoice.

(CA)

Dispensing

Submit the claim to VSP using the appropriate dispensing code (92340, 92341, 92342, 92352, or 92353), with applicable modifier, and bill with one unit of service. Do not bill VSP for lens materials.

Visually Necessary Contact Lenses

For specialty contact lenses that don’t meet a HCPCS definition, use V2799 and modifier NU or RA as appropriate. Attach an invoice detailing the wholesale cost of the contact lenses.

Visually necessary contact lenses are covered for eligible Medi-Cal members if one of the following conditions is present:

Aniridia (due to ocular condition)

Aphakia
Keratoconus
Nystagmus
Aniseikonia
Chronic pathology or deformity of nose, skin or ears
Anisometropia 3 or greater, or
When glasses are contraindicated due to chronic corneal or conjunctival pathology or deformity (other than corneal astigmatism);
High ametropia ±10.00D in at least one eye
Congenital Cone Dystrophy – allow red contacts

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Glasses to wear over contacts benefit

Spectacle lenses with frame to wear over visually necessary contacts is a covered benefit for eligible Medi-Cal members with one of the following conditions:

Aphakia (H27.01 - H27.03 or Q12.3)
High ametropia —10.00 diopters or greater
Presbyopia (H52.4)
Accommodative disorder
Binocular function disorder
Different prism requirements for distance and near vision
A prescription is required for the lenses

When glasses to be worn over contact lenses are visually necessary, call VSP at 800.615.1883 to request the spectacle lenses and frame authorization number at the same time or within 30 days of the contact lens claim submission date. For patients with keratoconus, request an authorization number for spectacle lenses and frame to be worn over contact lenses within 12 months of the contact lens claim submission date. Please have the relevant criteria information available when calling. Visual necessity must be documented in the patient’s file.

Frame

Two frames are covered for members who cannot wear bifocal lenses. See Bifocal Lenses or Two Pair in Lieu of Bifocals for criteria.

Deluxe frames (V2025) and safety frames (S0516) are covered when medically necessary. The provider determines medical justification based on patient needs. Use modifier NU to identify a new frame. Use modifier RA for a replacement frame.

Coordination of Benefits (IL)

(MI)

Note:

Bill with appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(NV)

Note:

(NH)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section above.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material.
You may request that the patient or guardian sign an Agreement of Financial Responsibility that clearly states that the patient is aware they are choosing to purchase non-covered services or materials. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

Missed Appointments

Medicaid members may not be billed for missed appointmen

(NY)

Non-Covered Services/Materials

Frame: If a non-covered frame is chosen, the patient pays the full cost of the frame.

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility form or equivalent that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-patient. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

(OH)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility form or equivalent that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

(OR)

Note:

Progressive lenses are considered a type of lens and not a lens option.

Visually Necessary Contact Lenses (SC)

Visually necessary contact lenses are covered in lieu of glasses.

(UT)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(VA)

Vision Therapy Sessions (92065): The first six vision therapy sessions are covered for visual necessity. If more than six sessions are required, the seventh and subsequent sessions billed require written documentation supporting the continuing need. Call VSP at 800.615.1883 to obtain an authorization number for Vision Therapy claim(s). Bill 92065 with appropriate diagnosis codes.

Client Exceptions (WV)

WV CHIP Details

Covered benefits include annual exams and eyewear. Lenses/frames or contacts are limited to a maximum benefit of $125 per year. The year starts on the date of service. The office visit and examination are covered in addition to the $125 eyewear limit. Families are responsible for paying the difference between the total charge for eyewear and the $125 allowance for lenses and frames.

(AZ)

Note:

Bill with the appropriate diagnosis codes and modifier KX, including NU or RA as appropriate. Visual necessity must be documented in the patient’s file.

(CA)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Patient Responsibility (IL)

Covered Services/Materials

Timely Filing (MI)

Providers must file claims within 12 months from the date of service to ensure compliance with Michigan Medicaid guidelines. Claims received outside of this timeframe may be denied for untimely submission.

(NV)

Note:

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

Repair (NH)

One repair of eyeglasses is covered every 12 months. Call VSP at 800.615.1883 for an authorization number.

Repair (NY)

Reimbursement is available for repair or replacement of eyeglass parts in situations where the damage is the result of causes other than defective materials or workmanship. Repair is unlimited. Authorization is required. Call VSP at 800.615.1883 for an authorization number.

Replacement (OH)

Replacement is allowed for loss, theft, or destruction beyond the patient’s control. Please retain a signed statement from patient documenting the circumstances in the patient’s file.

If the member has a prescription change, please refer to the initial and subsequent lens section in Materials Eligibility above.

Authorization is required. Call VSP at 800.615.1883 for an authorization number.

(OR)

Lenses: If the patient selects a lens not included on the VSP Oregon Medicaid Plan Professional Fee Schedule, the patient is responsible for the entire cost of the lens.
Lens Options: If the patient selects a lens option not included on the VSP Oregon Medicaid Plan Professional Fee Schedule, the patient must pay for the entire cost of that option. Any non-covered lens options would be a private transaction. Bill VSP for lens and frame if they are listed as covered materials on the VSP Oregon Medicaid Plan Professional Fee Schedule.
Frame: If the patient selects a frame that exceeds the allowance, the patient is responsible for the entire cost of the frame. Do not bill VSP for a frame that exceeds the frame allowance. For frame requirements, see Deluxe Frame section.

You may bill the patient for non-covered services or materials if all of the following requirements are met:

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility form or equivalent that clearly states that the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.
Do not bill VSP for non-covered services or materials. Treat this as a private- transaction and follow your private-pay patient policy.

(SC)

(UT)

Visually Necessary Contact Lenses

Replacement of contact lenses is covered when lost. Bill with appropriate diagnosis codes along with modifier KX. Visual necessity must be documented in the patient’s file.

(VA)

Note:

All vision therapy sessions should be billed with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Essential Medical Eye Care (WV)

Essential Medical Eye Care provides supplemental medical eyecare coverage for the detection, treatment and management of ocular and/or systemic conditions that produce ocular or visual symptoms. Members may see their VSP doctor when such a condition is suspected.

Covered benefits are administered according to the VSP policies and procedures in effect upon the date of service. Please click on the appropriate link below to view covered procedure codes for your state. Please note codes are only covered when appropriate based on your scope of licensure as well as the current laws, rules and regulations as determined by the State and Federal Government.

Essential Medical Eye Care

(AZ)

21 and over: Low Vision is not covered.

(CA)

Medi-Cal Beneficiaries Receiving Long-Term Care in a Skilled Nursing Facility

You are encouraged to verify that the facility belongs in one of the skilled nursing facility (SNF) categories (ICF/DD, NF-A or NF-B) and is licensed by the California Department of Public Health (CDPH). For more information, visit the CDPH Health Facilities page.

If the nursing facility is not a Medi-Cal Provider, use modifier KX to indicate that the recipient’s residency exemption was verified. When submitting claims, you must include the SNF’s name in the Name of Referring Provider or Other Source field (Box 17) on the CMS-1500 form. For electronic claims, the nursing facility’s NPI must be entered.

The Prison Industry Authority (PIA) fabricates lenses for members who reside in SNFs. Enter the facility’s NPI number on the e-order form when placing the order. You may contact the facility directly or review the National Plan and Provider Enumeration System (NPPES) Registry to obtain its NPI.

(IL)

Note:

Client Exceptions (MI)

Molina MMP members are eligible for post-cataract services (exam and materials following cataract surgery). See Post Cataract Enhancement Clients for complete information. Call VSP at 800.615.1883 to obtain an authorization number for Post Cataract services. Post Cataract services are covered with one of the following diagnosis codes: Z96.1, H27.00-H27.03, or Q12.3.

Michigan Federally Qualified Health Centers (FQHC) Providers must submit claims for Molina MI Medicaid members to Molina on a UB-04 form. For claims processing questions please contact Molina directly.

(NV)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility Form that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private pay-patient policy.

Replacement (NH)

20 and under: Replacement of lenses, or lenses and frames, is covered due to loss, broken, stolen or when the refractive error changes by +/-0.50 diopter or more in both eyes. Call VSP at 800.615.1883 for an authorization number.

21 and over: Replacement of lenses, or lenses and frames, is covered when the refractive error changes by +/-0.50 diopter or more in both eyes. Call VSP at 800.615.1883 for an authorization number. Lost glasses are not covered.

Replacement (NY)

Authorization is required. Call VSP at 800.615.1883 for an authorization number.

Eyeglasses

One replacement is available for lost, stolen, or broken eyeglasses every two years. The replacement eyeglasses should duplicate the original prescription and frames. Add modifier RB to the fitting and material procedures codes when billing for a complete replacement.
If the change in prescription is 0.50 diopter or greater in sphere or cylinder in one or both eyes.
During a two-year period, the member may change the frame size, style or material if a:

Visually Necessary Contact Lenses

May be replaced when lost or damaged.

Change in prescription is 0.50 diopter or greater in sphere or cylinder in one or both eyes.
The new prescription requires a larger frame.
The member is being treated for an allergic reaction to certain frame material.
Member has had a recent growth spurt or a significant loss/increase in weight

Post Cataract (OR)

Pregnant women, 21 and over: One pair of additional glasses is covered within 120 days following cataract surgery. Please call VSP at 800.615.1883 for authorization and benefit information.

Patient Responsibility (SC)

Timely Filing (UT)

File claims within 365 days of the date of service to ensure compliance with Utah Medicaid guidelines. Claims that are not filed within this timeframe may be denied. Any corrections to a claim must also be received and/or adjusted within the same 12-month time frame. If a correction is received after the deadline, no additional funds will be reimbursed.

(VA)

Virginia Premier FAMIS (19 and under) and Virginia Premier (21 and over, non-diabetic members): Vision Therapy is not covered.

Coordination of Benefits (AZ)

Patient Responsibility (CA)

Covered Services/Materials

(IL)

Note:

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(MI)

Note:

Bill visually necessary lens enhancements using the corresponding HCPCS code or miscellaneous HCPCS code with lab invoice based on fee schedule with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Repair and Replacement (NV)

Authorization is required; please call VSP at 800.615.1883 for an authorization number.

Repair or replacement as needed for the following:

A change in refractive error must exceed plus or minus 0.5 diopter or 10 degrees in axis deviation in order to qualify within the 12-month limitation.
or for broken or lost glasses

An additional exam is covered to determine if a change in prescription has occurred since the patient’s last exam. A change in refractive error must equal or exceed ±0.50 diopters.

Timely Filing (NH)

Providers must file claims within one hundred and twenty (120) days from the date of service to ensure compliance with New Hampshire Medicaid guidelines. Claims received outside of this timeframe may be denied for untimely submission.

Post-Cataract (NY)

Verify if coverage is available on Patient Record Report.

Aphakic with IOL (pseudophakia):
Post-surgical exam and one pair of eyeglasses or contact lenses after each cataract surgery with IOL insertion (diagnosis code Z96.1 is covered once per lifetime per operative eye.

Aphakic without IOL:
In addition to the post-surgical exam, aphakic patients who do not have an IOL (aphakia diagnosis codes H27.01, H27.02, or H27.03 are covered for the following lenses or combination of lenses when visually necessary:

Bifocal lenses in frames; or
Lenses in frames for distance vision and lenses in frames for near vision (two pairs of glasses); or
Conventional contact lenses for distance vision, eyeglasses for near vision to wear with contact lenses and eyeglasses to wear when the contact lenses have been removed.

Lens Materials

The following enhancements are covered following cataract extraction when visually necessary and documented by the treating physician:

Tints (V2744 - V2745)
Anti-reflective coating (V2750)
UV lenses (V2755)
Oversize lenses (V2780)

Repair (OR)

Authorization is required; please call VSP at 800.615.1883 to obtain an authorization.

The periodic adjustment of frames including tightening of screws is included in the original dispensing fee and should be conducted at no charge to the patient and is not eligible for reimbursement from VSP.

Authorized repairs may be billed using codes 92370 and 92371.

(SC)

Covered Services

The lens enhancements listed under Material Coverage are covered for patients 20 years of age and younger only.

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

Non-Covered Services/Materials

If the patient or guardian requests any non-covered services and/or materials, all of the following requirements must be met:

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material. Refer to the Advantage Network Lens Enhancement Chart for patient charges.
You may request that the patient or guardian sign an Agreement of Financial Responsibility that clearly states the patient is aware they are choosing to purchase non-covered services or materials. Keep the form in the patient’s records.

Essential Medical Eye Care (UT)

Essential Medical Eye Care provides supplemental eyecare coverage for the detection, treatment and management of ocular and/or systemic conditions that produce ocular or visual symptoms. Members can see their VSP doctor when such a condition is suspected.

Covered benefits are administered according to the VSP policies and procedures in effect upon the date of service. Please click on the appropriate link below to view covered procedure codes for your state. Please note codes are only covered when appropriate based on your scope of licensure as well as the current laws, rules, and regulations as determined by the State and Federal Government.

Essential Medical Eye Care

Patient Responsibility (VA)

Covered Services/Materials

Patient Responsibility (AZ)

Covered Services/Materials

(CA)

Note:

It’s the doctor’s responsibility to verify the eligibility status of each member at the time of service and obtain the appropriate authorization. Failure to obtain authorization doesn’t create a payment liability for the patient.
Providers must accept Medi-Cal’s maximum allowable as payment in full. Charges exceeding Medi-Cal allowances may not be billed to recipients.

(IL)

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility Form that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for non-covered services or materials. Treat this as a private-pay transaction and follow your private pay-patient policy.

Low Vision (MI)

A low vision evaluation is covered for members who present with moderate, severe, or profound visual impairment. See the Michigan Medicaid Fee Schedule for the appropriate CPT Evaluation and Management procedure code that best describes the service. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s).

A low vision evaluation includes, but is not limited to, a detailed case history, effectiveness of any low vision aids in use, visual acuity in each eye with best spectacle correction, steadiness of fixation, assessment of aids required for distance vision and near vision, evaluation of any supplemental aids, evaluation of therapeutic filters, development of treatment, counseling of patient and advice to patient’s family (if appropriate).

Low Vision Aids: Only basic and essential low vision aids are a benefit. Please submit a manufacturer’s invoice when submitting the claim.

Low vision rehabilitative services procedure codes (97112 and 97530) are not covered by VSP. Please refer to the patient’s health plan for coverage.

(NV)

Note:

Visual necessity must be documented in the patient’s file.

Essential Medical Eye Care Coverage (NH)

Essential Medical Eye Care provides supplemental medical eyecare coverage for the detection, treatment, and management of ocular and/or systemic conditions that produce ocular or visual symptoms. Members may see their VSP doctor when such a condition is suspected. Essential Medical Eye Care coverage is secondary to other medical eye insurance coverage that may reimburse you.

Essential Medical Eye Care

(NY)

Note:

Replacement (OR)

Authorization is required; please call VSP at 800.615.1883 for an authorization number.

20 and under and pregnant women: Unlimited replacement of lenses and frames if not due to patient negligence. Contact lens replacement is limited to visual necessity. Visual necessity must be documented in the patient’s medical record.

21 and over: Replacement of lens and frame is allowed every 12 months if medically necessary.

Contact lens replacement is limited to visual necessity up to a total of two contacts every 12 months. Visual necessity must be documented in the patient’s medical record.

Replacement (SC)

20 and under: Replacement glasses (frame and lenses, frame only, or lens(es) only) are covered if lost or destroyed, such as destroyed due to house fire, natural disaster, or an automobile accident. Reason for the replacement must be documented in the patient’s records.

(VA)

Note:

It’s the doctor’s responsibility to verify the eligibility status of each member at the time of service and obtain the appropriate authorization. Failure to obtain authorization doesn’t create a payment liability for the patient. You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays.

(AZ)

Note:

(CA)

Non-Covered Services/Materials

Frame: If a non-covered frame is chosen, the patient pays the full cost of the frame.

Lenses: The following lens options are not covered: V2730 and V2786. You may charge the patient your U&C fees for the non-covered options.

Trifocal lenses: If member is not currently wearing trifocal lenses, bill the patient your U&C for only the trifocal lenses. Bill VSP for the frame and the dispensing procedure codes.

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section.

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of their payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options and charges(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility form or equivalent that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private pay patient policy.

Missed Appointments

Medicaid members may not be billed for missed appointments.

Interim Examinations

Additional eye examination with refraction within 24 months is covered only when a sign or symptom indicates a need for this service. Please call VSP at 800.615.1883 for an authorization number.

Repair and Replacement (IL)

Authorization is required; please call VSP at 800.615.1883 for an authorization number.

Children less than 21 years of age do not have limits on glasses. Eyeglasses may be replaced as needed without prior approval if there is a change in the prescription meeting Illinois Department of Healthcare and Family Services requirements, or if they are broken beyond repair, lost, or stolen.

The difference between the old and new prescription is at least 0.75 diopters in either the sphere or cylinder component

Adults who are 21 years of age and older are limited to one pair of eyeglasses in a 24-month service period; however, this does not limit medically necessary eye examinations, or claims for repair/refitting of eyeglasses.

The Illinois Department of Healthcare and Family Services regards the maintenance of adequate records essential for the delivery of quality medical care. Providers must maintain an office record for each patient. The record maintained by the provider is to include the essential details of the patient’s condition and of each service or material provided. The signature of the provider is required for the record of the service/visit to be complete. If there is no signature, then the record is incomplete.

(MI)

Note:

For all low vision services, bill with appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Vision Therapy (NV)

Vision Therapy is covered as needed. Bill exam services (92060) and/or vision therapy sessions (92065) with appropriate diagnosis code(s). Vision therapy sessions are limited to one unit or visit per day.

Americans with Disability Access Guidelines (NH)

Offices are required to meet the ADA Accessibility Guidelines (ADAAG), which are available from the Department of Justice at (800) USA-ABLE or from The Access Board’s website at www.access-board.gov.

(NY)

Frames

Only standard frames are covered (V2020).

Timely Filing (OR)

For VSP to comply with Oregon Medical Assistance Program guidelines for encounter data submission, claims must be filed within 120 days of the date of service.

(SC)

Note:

Call VSP at 800.615.1883 to obtain an authorization number. When billing for replacement of eyeglasses (frame and lenses), frame only, or lens(es) only, visual necessity must be documented in the patient’s file.

(VA)

Aetna Better Health of Virginia, Aetna Better Health CCC Plus (20 and under), Aetna Better Health of Virginia FAMIS (19 and under), Virginia Premier (Diabetic members), Magellan Complete Care of Virginia (20 and under) and Virginia Premier (20 and under): Members may not be balance billed for any covered service.

Frames exceeding $35 are considered non-covered frames. If a non-covered frame is chosen, the patient pays the full cost of the frame. Do not balance bill the patient for any difference in cost.

Non-Covered Services/Materials

If the patient or guardian requests any non-covered service and/or material, you may bill the patient your usual and customary fees for the non-covered services or materials if all of the following requirements are met. For exceptions, please refer to Covered Services section .

The patient or guardian must be informed prior to services being rendered that this is a non-covered service or material. Advise the patient or patient’s guardian of payment responsibilities before providing services.
Provide the patient with information regarding the necessity, options, and charge(s) for the service/material(s).
The patient or guardian must sign an Agreement of Financial Responsibility form or equivalent that clearly states the patient is aware they are choosing to purchase non-covered services or materials as a private-pay customer. Keep the form in the patient’s records.

Do not bill VSP for these non-covered services or materials. Treat this as a private-pay transaction and follow your private-pay patient policy.

Repair (CA)

Repair is covered. Authorization is required; please call VSP at 800.615.1883 for an authorization number.

CPT codes 92370 and 92371 cannot be billed with HCPCS Code V2020 on the same date of service. Frame parts include nose pad arm with adjustable pad, nose pads, nose pad covers, temples and temple covers, and frame front.

Note:

Visual necessity must be documented in the patient’s file.

Vision Therapy (MI)

Vision Therapy is covered as needed. Bill exam services (92060) and/or vision therapy sessions (92065) with appropriate diagnosis code(s). 92499 used for unlisted ophthalmological service or procedure, used for vision therapy training aid.

(NV)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file. Issue an authorization under Vision Therapy.

Patient Rights and Responsibilities (NH)

In addition to the Patient Rights and Responsibilities outlined in the VSP Manual, Well Sense patients have the following rights and responsibilities:

A right to receive information about the organization (VSP / Well Sense) and member rights and responsibilities.
A right to voice complaints or appeals about the organization or the care it provides.
A right to make recommendations regarding the organization’s member rights and responsibilities policy.
A responsibility to supply information (to the extent possible) that the organization (VSP/Well Sense) needs in order to arrange care.
A responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.

Prime Health Choice members (NY)

Members are covered in full for exams every 12 months and materials every 24 months with a $200 material allowance to apply towards eyeglasses (lens and frame) or elective contact lenses. Allowance is covered only once per eligibility period.

If entire material allowance isn’t used at the initial visit, the remaining allowance cannot be used at a later date. You can balance bill the patient for any amount beyond the allowance.

Vision Therapy (OR)

Vision therapy is only covered for children (through age 20) for treatment of strabismus and other disorders of binocular eye movements. Bill the first six vision therapy sessions per calendar year with an appropriate diagnosis code (diagnosis codes may include but are not limited to those referenced in the Vision Therapy section of this manual). Issue an authorization under Vision Therapy.

(SC)

21 and over: Replacement is not a covered benefit.

Repair (VA)

Virginia Premier and Sentara (20 and under): For defective Otis & Piper frames, refer to the Lab Redo section for details.

Members 20 and under are eligible once every 12 months for repair. Authorization is required; please call VSP at 800.615.1883 for an authorization number.

Frame repair is billed using HCPCS code V2020 and modifier RP. The combination of V2020 and modifier RP shall pay the maximum allowable for repair and parts replacement.

Adults 21 and over: Lens and frame repairs are not covered

Non-covered services/materials are not eligible for repair.

(AZ)

Note:

You must accept payment by VSP as payment in full for services rendered and make no additional charge to any person for covered services, less any applicable copays

Replacement of lost, stolen, broken or damaged eyeglasses (CA)

Replacement of lost, stolen, broken or significantly damaged eyeglasses is covered more frequently than once every 24 months when justified. Limitation to eyewear orders or replacements are subject to utilization controls set by the Department of Health Care Services. The Medi-Cal labs ordering website detects excessive replacement requests and will ask for justification. Department of Health Care Services will deny abusive, fraudulent, and/or requests that are not justified.

Patient or patient’s representative/guardian is required to supply the provider with a signed statement.

The statement must certify the circumstances of the loss or destruction and the steps taken to recover the lost item. The signed statement must be retained in the provider’s record for at least three years.

Authorization is required; please call VSP at 800.615.1883 for an authorization number.

Lenses

Replacement lenses must meet the Materials Eligibility criteria above and one or more of the following:

±0.50D change in any corresponding meridian.
20 degrees or greater for cylinder power of .50-/62D.
15 degrees or greater for cylinder power of .75-.87D.
10 degrees or greater for cylinder power of 1.00-1.87D.
5 degrees or greater for cylinder power of 2.00D.
Change in axis of cylinder power of .12-.37D as sole reason for change is not covered.
Previous lens is lost, stolen, broken or marred to a degree significantly interfering with vision or eye safety.
Lens replacement is necessary because of frame replacement due to patient growth, metal allergy or other justifiable visual reasons.
Visual necessity must be documented in the patient’s medical record.

Frames

Replacement is allowed for loss, theft or destruction beyond the patient’s control; requires signed statement from patient with copy in file.

Frame replacement within two years of initial coverage is limited to the same model whenever possible.

A replacement frame won’t be covered if the existing frame can be made suitable for continued use by adjustment, repair or replacement of a broken front or temples. Replacement frames that are deliberately destroyed, abused or discarded by the patient aren’t covered.

A replacement frame may be covered for reasons other than those listed above if the patient signs a statement explaining the circumstances and the reason the existing frame cannot be used. Keep the signed statement in the patient’s file for a minimum of three years.

Timely Filing (IL)

File claims within 180 days of the date of service to ensure compliance with Illinois Medicaid guidelines. Claims that are not filed within this timeframe may be denied. Any corrections to a claim must also be received and/or adjusted within the same time frame. If a correction is received after the deadline, no additional funds will be reimbursed.

(MI)

Note:

For all vision therapy services, bill with appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file. Issue an authorization under Vision Therapy.

Timely Filing (NY)

File claims within 90 days of the date of service to ensure compliance with New York Medicaid guidelines for encounter data submission. Claims that are not filed within this timeframe may be denied.

(OR)

Note:

Additional sessions should be billed with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Vision Therapy (SC)

20 and under: Vision Therapy exams must be billed with 92060 and modifier KX. Visual necessity must be documented in the patient’s file. Vision Therapy training (92065) is not a covered benefit.

Call VSP at 800.615.1883 to obtain an authorization number for Vision Therapy claim(s).

Replacement (VA)

Members 20 and under replacement coverage is based on visual necessity and is typically limited to once every 12 months. Significant functional visual disability must exist, and standards of medical practice must be met before replacement glasses are prescribed. Authorization is required; please call VSP at 800.615.1883 for an authorization number.

Adults 21 and over: Lens and frame repairs are not covered

Non-covered services/materials are not eligible for replacement.

Medicaid Regulatory Compliance Appendix (NH)

New Hampshire Network Doctor Agreement

(AZ)

To dispute or appeal a claim based on a claim denial or dissatisfaction with a claim payment, you may challenge the claim denial or adjudication by filing a formal claim dispute or appeal.

If you wish to file a claim dispute or appeal, follow the instructions provided below. Appeals must be received within sixty (60) calendar days for Arizona Medicaid members.

All claim disputes related to a claim for covered services of Arizona Health Care Cost Containment System (AHCCCS) member must be filed in writing to VSP and must be received:

no later than 12 months from the date of service;
12 months after the date of eligibility posting; or
within sixty (60) days after the payment, denial or recoupment of timely claims submission, whichever is later.

Incomplete appeals will be returned.

Mail: Send appeals to: VSP Claim Appeals, PO Box 2350, Rancho Cordova, CA 95741-2350.

Online: Complete the Provider Dispute Resolution Request Form available in the Forms Library under Administration on VSPOnline on eyefinity.com.

Client Exceptions (CA)

Member Identification Number

These clients report members by an alpha/numeric identification number comprised of 8 digits and 1 alpha character:

Anthem Blue Cross
CalOptima
CalOptima OneCare
Central Coast Alliance for Health
Gold Coast Health Plan
LA Care Health Plan (traditional Medicaid)
Positive Healthcare
Santa Clara Family Health Plan

These clients report members by an alpha/numeric identification number comprised of 8 digits and 1 alpha character or their SSN:

Community Health Group
Kern Health Systems

These clients report members as follows:

Health Plan of San Joaquin: Members are reported by a 9-digit identification number starting with 200.

Partnership HealthPlan of CA: Members are reported by an identification number comprised of 8 digits, 1 alpha character, plus 1 digit.

San Francisco Health Plan: Members are reported by an 11-digit identification number.

You may obtain a recipient’s Medi-Cal Benefits Identification Card number (BIC’s I.D.) on the Automated Eligibility Verification System (AEVS) using a valid Social Security Number and date of birth. This information is available on AEVs, Point of Service devices, and Transaction Services on the Medi-Cal website. PIA account holders can also get the current issue date from the 14 digit BIC # retrieved by running the eligibility check using PIA Optical Online website.

Cultural Competency and Language Assistance (IL)

Cultural Competence Training

All Network doctors who serve IL Medicaid patients are to complete and attest to having completed, training which is provided by VSP or another source, prior to being added to the VSP Medicaid network and annually thereafter. Network doctors who own their practice are required to attest annually that they and their staff, including employee doctors, have completed the training. The training modules include:

Cultural Competency
Better Communication, Better Care: Provider Tools to Care for Diverse Populations
Seniors and Persons with Disabilities
Patients’ Rights and Responsibilities

Training will be emailed to practices annually. Network doctors must ensure and attest that their employees have completed training provided by VSP or another source, and to provide evidence of such completion if requested by VSP. Electronic signatures on training attestations (which will also be in the email) are required to show proof of completion.

Providers must retain records of training for a period of 10 years.

American Sign Language (ASL) Interpreter Requests

Under the Americans with Disabilities Act of 1990, eye doctors and other health care providers are required under this federal law to provide American Sign Language (ASL) interpreter services, at no cost to the patient, to patients who need and request ASL interpreter services.

Essential Medical Eye Care Coverage (MI)

Essential Medica Eye Care provides supplemental medical eyecare coverage for the detection, treatment, and management of ocular and/or systemic conditions that produce ocular or visual symptoms. Members may see their VSP doctor when such a condition is suspected.

Covered benefits are administered according to the VSP policies and procedures in effect upon the date of service. Please click on the appropriate link below to view the covered procedure codes for your state. Please note codes are only covered when appropriate based on your scope of licensure as well as the current laws, rules and regulations as determined by the State and Federal Government.

Essential Medical Eye Care

Essential Medical Eye Care (NY)

Essential Medical Eye Care provide supplemental medical eyecare coverage for the detection, treatment and management of ocular and/or systemic conditions that produce ocular or visual symptoms. Members may see their VSP doctor when such a condition is suspected.

Senior Whole Health: Members are not eligible to receive Essential Medical Eye Care services.

Essential Medical Eye Care

Eligibility & Authorization

Eligibility is provided directly by Centers Plan for Healthy Living. For additional questions about eligibility, paper claims and benefits, check your patient’s ID card for information and the contact phone number. Keep a copy of the ID card in your patient’s file.

Sample ID

Essential Medical Eye Care Coverage (OR)

Essential Medical Eye Care

(SC)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

Client Exceptions (VA)

Aetna Better Health Virginia DSNP 30079796

Aetna Better Health Disabled and Special Needs Population (DSNP) offers an exam every 12 months and materials every 12 months with a $300 allowance.

If entire material allowance isn’t used at the initial visit, the remaining allowance cannot be used at a later date. You can balance bill the patient for any amount beyond the allowance. For details, see the Patient Responsibility section.

Dual Coverage: Some members may have two Aetna Better Health plans (D-SNP and MLTSS) under separate ID numbers. Be sure to check with your patient if they are covered under both plans and if so, get both ID numbers to verify eligibility. Bill exam and glasses, if eligible, under MLTSS and bill contacts under DSNP. Members can coordinate between the two plans to pay for overages. If coordinating benefits, D-SNP would be primary, MLTSS would be secondary.

Aetna Better Health Virginia CCC Plus (MLTSS) 30077004

Aetna Better Health CCC Plus is a Managed Long-Term Services and Support (MLTSS) plan. Aetna Better Health CCC Plus offers members 21 and over a routine exam every 12 months and materials every 12 months with a $250 allowance. Allowance is covered only once per eligibility period.

Magellan Complete Care of Virginia 30076612 – Adults 21 and over

Magellan Complete Care of Virginia offers members 21 and over a routine exam every 24 months and materials every 24 months with a $150 allowance. Allowance is covered only once per eligibility period.

Virginia Premier DSNP 300083229 – Client termed 12/31/22

Providers must file claims within 12 months from the date of service to ensure compliance with Virginia Medicaid guidelines. Claims received outside of this timeframe may be denied for untimely submission.

Virginia Premier Disabled and Special Needs Population (DSNP) offers a routine exam every 12 months and materials every 12 months with a $300 allowance.

Dual Coverage: Some members may have two VA Premier plans (D-SNP and MLTSS) under separate ID numbers. Be sure to check with your patient if they are covered under both plans and if so, get both ID numbers to verify eligibility. Members can coordinate between the two plans to pay for overages. If coordinating benefits, D-SNP would be primary, MLTSS would be secondary.

Virginia Premier MLTSS 30076353

Virginia Premier Managed Long Term Services and Support (MLTSS) offers a routine exam every 12 months.

Members (Over 21) are eligible for materials every 12 months with a $100 frame allowance.

Members under 21 are eligible for materials every 12 months with the Elements benefit.

Sentara Health Plan 40149870 / 40148184

Members (Over 21) are eligible for materials every 12 months with a $100 frame allowance.

Members under 21 are eligible for materials every 12 months with the Elements benefit.

Repair and Replacement (AZ)

Authorization is required; please call VSP at 800.615.1883 for an authorization number.

20 and under: Repair or replacement as needed. Authorization is required; please call VSP at 800.615.1883 for an authorization number.

21 and over: Repair and replacement is not covered

(CA)

Note:

Transaction Services on the Medi-Cal website will ask for an issue date. You can use the current date to submit the eligibility requests to retrieve the current Medi-Cal I.D.

VSP Members Language Assistance Program (IL)

VSP provides Cultural Competency training on the Training & Support section of VSPOnline. Several resources addressing topics of interpretation services, better communication, health literacy and census information are available in addition to the training modules.

VSP has implemented a Language Assistance Program (LAP) to provide linguistic services to enrollees who prefer to conduct their affairs in a language other than English including the availability of free interpreter services at the time of an appointment for patients who request them.

Document Translation and Alternative Formats

Members who prefer their VSP member materials in a language other than English can receive free translation of VSP member documents, including alternative formats such as Braille, large format and audio. You may contact VSP Customer Care at 800.615.1883 for more information.

Interpretation

VSP provides telephone interpretation services to any VSP member who prefers to communicate with VSP about their benefits in a language other than English, including TTY/TDD for those who are hearing impaired.

VSP members who want to discuss their benefits in another language can call VSP at 800.877.7195 and indicate their language need. Members can also visit vsp.com to see a list of VSP practices where language(s) other than English are spoken.

You are required to keep your office(s) language capabilities current so members know where they can receive services in languages other than English. We encourage you to review practice information quarterly on VSPOnline at eyefinity.com.

Practices must keep in mind that family, friends, and minor children are considered untrained health interpreters. Using family, friends, and minor children poses a problem with patient privacy. In addition, family may impose their view of the patient and their health that can lead to less than the highest quality care desired. To request face-to-face interpretation services at no cost to you or your patient, contact VSP customer Care at 800.615.1883.

(NY)

Referral Process

Patients have direct access to any participating VSP Integrated Primary EyeCare provider. Participating providers are listed on the Centers Plan for Health Living website at www.centersplan.com. Services that are approved will be applied to the member’s medical benefit.

(SC)

21 and over: Vision Therapy is not a covered benefit.

Timely Filing (VA)

(AZ)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(CA)

Anthem-Termed - 12/31/2022

Anthem Medi-Connect (Client IDs 30049369 and 30050240) offers a routine exam every 12 months and materials every 24 months with allowance to go towards materials. Allowance is covered only once per eligibility period and varies by county (Los Angeles $175 allowance, Santa Clara $100 allowance).

Coordination of Care for Medicare-Medicaid Plan (MMP) Members

You and/or your patient may be asked to participate in care planning and management by a member of Anthem’s case management/service coordination team. The goal is to ensure that patients experience seamless transitions across health care settings, providers and services.

To have a copy of your patient’s care plan faxed or mailed to you or to reach their care team, call the number provided on their identification card.

CalOptima OneCare

CalOptima OneCare (Client ID 12264659) offers a routine eye exam every 12 months. Materials are offered every 24 months with a $250 allowance. Allowance is covered only once per eligibility period.

CalOptima OneCare members are eligible for post-cataract services (exam and $100 material allowance following cataract surgery). Call VSP at 800.615.1883 to obtain an authorization number for Post Cataract services. Post Cataract services are covered with one of the following diagnosis codes: Z96.1, H27.00-H27.03, or Q12.3.

Please verify eligibility to determine which laboratory should be used.

CalOptima OneCare Connect -Termed 12/31/2022

CalOptima OneCare Connect (Client ID 30058212) offers a routine exam every 12 months and materials every 24 months with a $300 allowance. Allowance is covered only once per eligibility period.

Please verify eligibility to determine which laboratory should be used.

For all non-vision related questions, refer member to OneCare Connect toll free at 855.705.8823 or TTY/TDD at 800.735.2929.

CalOptima PACE - Termed 12/31/2022

CalOptima PACE (Client ID 30058212, Division 0208) offers a routine exam every 12 months and materials every 12 months with a $200 allowance. Allowance is covered only once per eligibility period.

Blue Shield of California Promise Health Plan Medi-Connect – Termed 12/31/2022

Blue Shield of California Promise Health Plan Medi-Connect (Client ID 30084320) offers a routine exam every 12 months and materials every 24 months with a $500 allowance. Allowance is covered only once per eligibility period.

Community Health Group

Community Health Group (Client ID 12017488) offers a routine eye exam every 12 months, to diabetic patients. All other eligible adults (21 and older) are offered a routine eye exam every 24 months.

Community Health Group Medi-Connect (Client ID 30041019) offers a routine exam and materials every 12 months with a $300 allowance. Allowance is covered only once per eligibility period.

Gold Coast Health Plan

Gold Coast Health Plan (Client ID 30029924) members are only able to receive services from VSP Medicaid doctors within Ventura County. All members with diabetes receive a routine eye exam every 12 months.

File claims within 180 days of the date of service. Claims that are not filed within this timeframe may be denied or subject to reduction in payment in compliance with California Medicaid guidelines.

Kern Health Systems

Kern Health Systems (Client ID 12049397) offers a routine eye exam every 12 months, to diabetic patients. All other eligible adults (21 and older) are offered a routine eye exam every 24 months.

LA Care Health Plan

For LA Care Health Plan (Client ID 12290367) members when visual necessity is identified but does not meet the criteria listed, you may contact VSP to request specific benefit review for your patient prior to rendering services. Specific benefits available for review include necessary contact lenses and low vision.

For practices seeing members of this health plan, an Industry Collaboration Effort (ICE) Language Self-Assessment must be completed annually and kept on file for each staff member who offers linguistic services. Download and print the Self-Assessment.

You are required to download and print a flier and post it in your practice to let your patients know that you can assist them in languages other than English.

(IL)

Note:

If a patient insists that the provider or staff communicate with bilingual family or friends, document in the member patient record that the VSP member refuses interpreter services and/or uses friend or family to interpret.

(NY)

Reimbursement

Centers Plan for Healthy Living handles reimbursement and pays claims daily following state and federal regulations. Reimbursement is based on your current VSP contracted rates.

Submitting Claims

Please refer to the patient’s ID card from Centers Plan for Healthy Living for directions on submitting claims.

Essential Medical Eye Care Coverage (SC)

Covered benefits are administered according to the VSP policies and procedures in effect upon the date of service. Please click on the link below to view the covered procedure codes for your state. Please note codes are only covered when appropriate based on your scope of licensure as well as the current laws, rules, and regulations as determined by the State and Federal Government.

VSP’s Essential Medical Eye Care services approximate South Carolina’s Medicaid fee-for-service schedule. Reimbursement for approved Medicaid procedures will be 80% of your U&C fee or VSP Medicaid fee schedule, whichever is lower.

Essential Medical Eye Care

Essential Medical Eye Care Coverage (VA)

Essential Medical Eye Care

Vision Therapy (AZ)

20 and under: Vision Therapy is covered as needed. Call VSP at 800.615.1883 to obtain an authorization number for Vision Therapy claim(s). Bill exam services (92060) and/or vision therapy sessions (92065) with appropriate diagnosis code(s).

21 and over: Vision Therapy is not covered.

(CA)

Note:

Failure to meet the training requirement may lead to removal from the VSP Medicaid Network.

(IL)

Documentation

The following items should be documented in the patient’s medical record and/or patient history form:

Patient’s preferred written and spoken language
Refusal of interpreter (if applicable)
Use of interpreter and who (family member, minor, friend, doctor, office staff, or trained professional interpreter)
Patient requests to have interpretation services

It is suggested to also document the patient’s race and ethnicity with an option for the patient not disclose this information.

(NY)

Note:

Only claims covered up to the scope of Integrated Primary Eyecare should be submitted to Centers Plan for Healthy Living. Continue to submit claims for routine eyecare to VSP.

(AZ)

Note:

Bill with the appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.

(CA)

Prison Industry Authority Lab

All providers are instructed to use Prison Industry Authority (PIA) optical laboratories to fabricate lenses for dates of service on or after January 1, 2020. If a specialized lens or material is prescribed that PIA is unable to fabricate, the ophthalmic lens orders must be fabricated at a non-PIA optical laboratory. See Non-PIA (Private) Lab.

Processing Period

Allow five working days to process prescriptions with combined sphere-cylinder power of less than 7.12 diopters.

Ten working days is required to process prescriptions with combined sphere-cylinder power of more than 4 diopters, or other special orders.

Delivery time to and from the optical laboratory is not included in the specified turnaround times.

Working with the PIA labs

VSP, the PIA labs, and the Department of Health Services encourage you to follow these steps to address any concerns.

Contact the PIA lab directly, especially if there is a problem with a prescription order.

If you don’t get the desired results by contacting the lab, contact the Lab Manager of the facility.

If the problem still isn’t resolved, contact the PIA Headquarters office. This person can address problems not resolved in steps 1 or 2.

If the first three steps don’t produce satisfactory results, your final recourse is to contact the Department of Health Services.

PIA Optical Labs Contact List

Name	County Code (s)
California State Prison Solano Prison Industry Authority Optical Lab 2100 Peabody Road Vacaville, CA 95687-6615 Customer Service 800.700.9861 707.454.3447 Superintendent II 707.451.0182, ext. 6625 Fax 707.454.3214	Alameda: 01 Alpine: 02 Amador: 03 Butte: 04 Colus: 06 Contra Costa: 07 Del Norte: 08 El Dorado: 09 Glenn: 11 Humboldt: 12 Lake: 17 Lassen: 18 Marin: 21 Mendocino: 23 Modoc: 25 Napa: 28 Nevada: 29	Placer: 31 Plumas: 32 Riverside: 33 Sacramento: 34 San Bernardino: 36 San Francisco: 38 Santa Clara: 43 Santa Cruz: 44 Shasta: 45 Sierra: 46 Siskiyou: 47 Solano: 48 Sonoma: 49 Sutter: 51 Tehama: 52 Trinity: 53 Yolo: 57 Yuba: 58
	Note: All counties should submit glass orders to CSP-SOL
Valley State Prison for Women/ CCWF Prison Authority Optical Lab CCWF/VSPW 23370 Road 22 Chowchilla, CA 93610-4329 Customer Service 800.377.8953 x7427 Superintendent II 559.665.6100 x6253 Fax 559.665.5147	Calaveras: 05 Fresno: 10 Imperial: 13 Inyo: 14 Kern: 15 Kings: 16 Los Angeles: 19 Madera: 20 Mariposa: 22 Merced: 24 Mono: 26 Monterey: 27 Orange: 30*	San Benito: 35 San Diego: 37 San Joaquin: 39* Stanislaus: 50* Tulare: 54 Tuolumne: 55 Ventura: 56
Department of Health Services, Vision Care Program Consultant: Donny Shiu, OD Medi-Cal Vision Care Program Consultant California Department of Health Care Services P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 Phone: 916.445.4884 Fax: 916.440.5640 E-mail: donny.shiu@dhcs.ca.gov

Americans with Disability Access Guidelines (NY)

Offices are required to meet the ADA Accessibility Guidelines (ADAAG), which are available from the Department of Justice at 800.USA.ABLE or from The Access Board’s website at www.access-board.gov. For information and technical assistance contact the United Sates Department of Justice Civil Rights Division at 800.514.0301 or http://www.ada.gov/.

Essential Medical Eye Care (AZ)

Covered benefits are administered according to the VSP policies and procedures in effect upon the date of service. Please click on the appropriate link below to view covered procedure codes for your state. Please note codes are only covered when appropriate based on your scope of licensure as well as the current laws, rules, and regulations as determined by the State and Federal Government.

Essential Medical Eye Care

(CA)

Note:

When using a PIA lab, submit the claim to VSP using the appropriate dispensing code (92340, 92341, 92342, 92352, or 92353), with applicable modifier, and bill with one unit of service. Do not bill VSP for lens materials.

Critical Incident Reporting (NY)

Contact the appropriate heath plan directly to report critical incidents, such as patient abuse, neglect, exploitation, rights violations or serious injury. Use the standard contact information provided on the patient’s card if one has not been provided below.

Please be sure to specifically state this is a reporting of a “Critical Incident” as a safeguard to ensure all involved recognize this type of call. This will ensure the right escalation process is followed and appropriate protective services can be notified.

Centers Plan for Healthy Living
Julie Seifert
JSeifert@centersplan.com
718.215.7000 x3126

Senior Whole Health of New York
Quality Management Director
617.494.5353

(CA)

Note:

Effective 2/01/2020, the counties of Orange, San Joaquin, and Stanislaus submit materials to CSP-Solano Optical Lab.

New York IPA Agreement (NY)

Eastern Vision Service Plan IPA, Inc. IPA Agreement

(CA)

Non-PIA (Private) Lab

If authorized, ophthalmic lens orders that cannot be fabricated by PIA must be made at a non-PIA (private) optical laboratory. When using a non-PIA lab, submit the claim to VSP using the appropriate code for ophthalmic lenses (HCPCS codes V2100 – V2499), miscellaneous lens items (V2700 – V2799), and dispensing services (CPT codes 92340 – 92342 and 92352 – 92353).

Bill with the appropriate diagnosis codes and modifier KX. Note “PIA Denied” in Box 19 of the CMS-1500 claim form.

(CA)

Note:

All procedure codes for materials must be billed with the appropriate modifier:
NU – new equipment
RA – replacement
KX – specific required documentation on file; you may also use modifier KX to indicate that the recipient’s residency exemption at skilled nursing facilities has been verified or that the member has previously worn trifocals.

(CA)

Claims billing with an allowance plan:

Not required to use a PIA lab for fabrication of materials, lens and frame.
Not required to use modifiers when billing for ECL materials.
Dispensing (92340, 92341, 92342) applies towards the plan’s allowance.

Language Requirements (CA)

For Medicaid practices across California, an Industry Collaboration Effort (ICE) Language Self-Assessment should be completed annually and kept on file for each staff member who offers linguistic services. Download and print the Self-Assessment

Timely Claim Filing (CA)

File claims within 180 days of the date of service. Submissions received over 180 days from the month of service, or if the received date of the adjustment is greater than 6 months from the month of the original EOP date, are subject to reduced reimbursement in accordance with state guidelines (MMCD Policy Letter 08-002.)

Coordination of Benefits (CA)

Private health insurance belonging to a Medi-Cal beneficiary must be billed first before billing Medi-Cal. Medi-Cal may be billed for the balance, including other health coverage (OHC) co-payments, OHC co-insurance and OHC deductibles.

Verify members' eligibility through Medi-Cal. If the patient has additional vision or health insurance coverage and you aren’t a participating doctor with that carrier, refer the member to the primary insurance carrier. If you participate with the OHC contact the other patient’s OHC for eyewear ordering and billing information. Submit the claim to the OHC and then submit the claim to VSP along with a copy of the other insurance’s Explanation of Benefits (EOB), Remittance Advice (RA) or denial letter. Patients with OHC aren’t eligible for Prison Industry Authority (PIA) contracted services.

Coordinated claims are subject to timeliness filing guidelines (see Timely Claim Filing).

Note: If the patient has an OHC indicator, or if the PIA lab rejects the prescription because the patient has other health insurance indicator, ask the patient if they have other insurance. If the patient denies carrying other insurance, contact the Medi-Cal Other Health Care unit at 800.541.5555, or 916.636.1980 if you are located outside of California. You may also access the OHC forms at http://www.dhcs.ca.gov/services to remove or modify the invalid OHC indicator.

Denied Claim Appeals (CA)

Please see Claim Appeals in the VSP Provider Reference Manual for more information.

Services Provided Out of the Office (CA)

Service(s) typically provided in the office can be provided out of the office at the request of the patient, in addition to basic service (bill with modifiers 22 and KX).

99056 – This code must be billed with modifiers 22 and KX and one of the following CPT codes on the same date of service: 92002, 92004, 92012, 92014, 92310-92312.

Low Vision (CA)

A low vision evaluation is covered for members who present with moderate, severe, or profound visual impairment. See the California Medicaid Fee Schedule for the appropriate CPT Evaluation and Management procedure code which best describes the service. Call VSP at 800.615.1883 to obtain an authorization number for Low Vision claim(s).

HCPCS codes V2600 – V2615 must be billed with an appropriate modifier on the claim for payment: Modifiers required for billing low vision aids include:

NU New equipment

RA Replacement of a Durable Medical Equipment item

Low Vision Aids: Only basic and essential low vision aids are a benefit. Please submit a manufacturer’s invoice when submitting the claim.

Low vision rehabilitative services procedure codes (97112 and 97530) are not covered by VSP. Please refer to the patient’s health plan for coverage.

(CA)

Note:

For all low vision services, bill with appropriate diagnosis codes and modifier KX. Visual necessity must be documented in the patient’s file.
Effective 1/1/2020 the State of CA no longer covers Vision Therapy, coverage for Low Vision only.

Essential Medica Eye Care Coverage (CA)

Essential Medical Eye Care

Medicaid Fee Schedules

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Last Updated: N/A

This material is confidential, intended for the use by VSP doctors only. The contents may not be shared with any unauthorized person. This manual is the property of VSP.

Professional Fee Schedule for Routine Services (AZ)

Effective 2/1/14

Reimbursement for routine vision care services is based on the lesser of the billed amount or the maximum allowable reimbursement as reflected on this fee schedule. Fees are subject to change with notification from VSP.

Exam Services

92002	Intermediate exam, new patient	$38.00
92004	Comprehensive exam, new patient	$50.00
92012	Intermediate exam, established patient	$35.00
92014	Comprehensive exam, established patient	$47.00
92015	Determination of refractive state	$5.00

Dispensing and Material Services

Frame Use modifier NU to identify new frame. Use modifier RA to identify replacement frame.
V2020	Frame		$26.60
Dispensing:
92340	Fitting of spectacles, except for aphakia, monofocal		$12.56
92341	Fitting of spectacles, except for aphakia, bifocal		$16.29
92342	Fitting of spectacles, except for aphakia, multifocal		$18.74
Single Vision Lenses, per lens: Use modifier NU to identify new lens(es). Use modifier RA to identify replacement lens(es).
V2100	Sphere, plano to ± 4.00d		$6.38
V2101	Sphere, ± 4.12 to ± 7.00d		$6.38
V2102	Sphere, ± 7.12 to ± 20.00d		$10.21
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder		$6.38
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder		$6.38
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder		$10.21
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder		$10.21
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder		$6.38
V2108	Spherocylinder, ± 4.25d to ± 7.00d sphere, 2.12 to 4.00d cylinder		$6.38
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder		$10.21
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder		$10.21
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder		$10.21
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder		$10.21
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder		$10.21
V2114	Spherocylinder, sphere over ± 12.00d		$10.21
V2115	Lenticular, (myodisc)		$19.00
V2118	Aniseikonic lens		$19.00
V2121	Lenticular lens		$19.00
V2199	Specialty single vision. Must be billed with modifier KX. Visual necessity must be documented in the patient’s file.		$10.21
Bifocal Lenses, per lens: Use modifier NU to identify new lens(es). Use modifier RA to identify replacement lens(es).
V2200	Sphere, plano to ± 4.00d		$12.43
V2201	Sphere, ± 4.12 to ± 7.00d		$12.43
V2202	Sphere, ± 7.12 to ± 20.00d		$17.20
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder		$12.43
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder		$12.43
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder		$17.20
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder		$17.20
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder		$12.43
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder		$12.43
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder		$17.20
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder		$17.20
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder		$17.20
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder		$17.20
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder		$17.20
V2214	Spherocylinder, sphere over ± 12.00d		$17.20
V2215	Lenticular (myodisc)		$28.30
V2218	Aniseikonic		$28.30
V2219	Seg width over 28mm		$8.00
V2220	Add over 3.25d		$8.00
V2221	Lenticular lens		$28.30
V2299	Specialty bifocal. Must be billed with modifier KX. Visual necessity must be documented in the patient’s file.		$17.20
Trifocal Lenses, per lens: Use modifier NU to identify new lens(es). Use modifier RA to identify replacement lens(es).
V2300	Sphere, plano to ± 4.00d		$18.03
V2301	Sphere, ± 4.12 to ± 7.00d		$18.03
V2302	Sphere, ± 7.12 to ± 20.00d		$22.93
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder		$18.03
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder		$18.03
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder		$22.93
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder		$22.93
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder		$18.03
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder		$18.03
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder		$22.93
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder		$22.93
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder		$22.93
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder		$22.93
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder		$22.93
V2314	Spherocylinder, sphere over ± 12.00d		$22.93
V2315	Lenticular (myodisc)		$34.31
V2318	Aniseikonic lens		$34.31
V2319	Seg width over 28mm		$12.00
V2320	Add over 3.25d		$12.00
V2321	Lenticular lens		$34.31
V2399	Specialty trifocal. Must be billed with modifier KX. Visual necessity must be documented in the patient’s file.		$22.93
Variable Asphericity Lenses, per lens: Use modifier NU to identify new lens(es). Use modifier RA to identify replacement lens(es).
V2410	Single vision, full field, glass or plastic		$30.00
V2430	Bifocal, full field, glass or plastic		$55.00
V2499	Variable asphericity lens, other type. Must be billed with modifier KX. Visual necessity must be documented in the patient’s file.		$55.00
Miscellaneous Covered Services, per lens: Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP Arizona Medicaid Client Details for requirements. Use modifier NU to identify new lens(es). Use modifier RA to identify replacement lens(es).
V2700	Balance lens		$36.16
V2710	Slab off prism, glass or plastic		$50.11
V2715	Prism		$9.59
V2718	Press-on lens, fresnel prism		$23.57
V2730	Special base curve, glass or plastic		$16.91
V2744	Photochromic		$10.15
V2750	Antireflective coating		$14.79
V2755	UV lens		$10.28
V2760	Scratch resistant coating		$13.00
V2770	Occluder lens		$16.10
V2780	Oversize lens		$10.34
V2781	Progressive lens		$36.00
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate		$39.11
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate		$44.10
V2784	Lens, polycarbonate or equal, any index		$28.68
V2799	Vision service, miscellaneous		Submit invoice for pricing*
Repair/Refitting (see Arizona Medicaid Client Details):
92370	Repair and refitting spectacles, except for aphakia		$23.56
92371	Repair and refitting spectacles, spectacle prosthesis for aphakia		$9.23
Visually Necessary Contact Lenses
Visually Necessary Contact Lenses Contact lenses are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP Arizona Medicaid Client Details for requirements. Use modifier NU to identify new contact lens(es). Use modifier RA to identify replacement contact lens(es).		Maximum allowance per eye
V2500	PMMA, spherical	$61.24
V2501	PMMA, toric or prism ballast	$96.30
V2502	PMMA, bifocal	$140.90
V2503	PMMA, color vision deficiency	$97.81
V2510	Gas permeable, spherical	$82.31
V2511	Gas permeable, toric or prism ballast	$133.04
V2512	Gas permeable, bifocal	$154.46
V2513	Gas permeable, extended wear	$141.71
V2520	Hydrophilic, spherical	$72.62
V2521	Hydrophilic, toric or prism ballast	$126.43
V2522	Hydrophilic, bifocal	$164.05
V2523	Hydrophilic, extended wear	$104.85
V2530	Scleral	$155.30
V2531	Scleral, gas permeable	$370.15
V2599	Contact lens, not otherwise classified.	$164.05
Visually Necessary Contact Lens Fitting and Dispensing Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Visual necessity must be documented in the patient’s file. Service must be billed with modifier KX. See VSP Arizona Medicaid Client Details for requirements.
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia		$71.88
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye		$75.87
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes		$86.47
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens		$75.77
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens, both eyes, except for aphakia		$59.18
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye		$57.28
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes		$77.16
92317	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens		$55.70
92325	Modification of contact lens		$28.23
92326	Replacement of contact lens		$26.94

Low Vision Services


Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Arizona Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92354	Fitting of spectacle mounted low vision aid; single element system	$29.38
92355	Fitting of spectacle mounted low vision aid; telescopic/other compound lens system	$25.68
92499	Unlisted ophthalmological service or procedure Use this code to bill for low vision exams	$70.00
V2600	Hand held low vision and other nonspectacle mounted aids Use modifier NU to identify new equipment. Use modifier RA to identify replacement.	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids Use modifier NU to identify new equipment. Use modifier RA to identify replacement.	Submit invoice for pricing*
V2615	Telescopic and other compound lens system, including distance vision, telescopic Use modifier NU to identify new equipment. Use modifier RA to identify replacement.	Submit invoice for pricing*

Vision Therapy


Orthoptic. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP Arizona Medicaid Client Details for requirements.
92060	Sensorimotor examination with multiple measurements of ocular deviation	$47.65
92065	Orthoptic training; performed by a physician or other qualified health care professional	$39.22

Professional Fee Schedule for Routine Services (CA)

Effective 6/1/16

Exam Services

Evaluation and Management services are covered through the Primary EyeCare plan.

92002	Intermediate exam, new patient	$29.52
92004	Comprehensive exam, new patient	$35.50
92012	Intermediate exam, established patient	$20.33
92014	Comprehensive exam, established patient	$35.50
92015	Determination of refractive state	$7.21

Using Prison Industry Authority (PIA) Labs

For services provided to Medi-Cal members, please verify with PIA that they can supply the lens/materials. Please verify if a Medi-Cal Treatment Authorization Request (TAR) is required.

If PIA is not able to provide the lens/materials, bill VSP for the non-supplied PIA lens or materials. Bill with the appropriate diagnosis codes and modifier KX. Put “PIA Denied” in Box 19.

Dispensing and Material Services

Submit claims for lens materials and frames, including replacement parts, to PIA. Use modifier NU to identify new lens(es). Use modifier RA when replacing lens(es). Use KX and RA to identify current trifocal wearers.See VSP California Medicaid Client Details page.


Single Vision Dispensing Services:
92340	Fitting of spectacles, except for aphakia, monofocal, other than bifocal per pair	$19.39
92352	Fitting of spectacles, prosthesis for aphakia, monofocal, per pair	$19.39
Bifocal Dispensing Services:
92341	Fitting of spectacles, except for aphakia, bifocal, per pair	$28.62
92353	Fitting of spectacles, prosthesis for aphakia, multifocal, per pair	$28.62
Trifocal Dispensing Services: Only patients currently wearing trifocal lenses are covered. Medical necessity must be documented in the patient’s medical record. Use modifier KX and RA. KX is used to indicate that documentation is on file stating that the recipient is a current trifocal wearer and not a first time wearer.
92342	Fitting of spectacles, except for aphakia, multifocal other than bifocal, per pair	$39.38
Frames: Use modifier NU to identify new frame. Use modifier RA to identify replacement of frame. See client detail pages.
V2020	Frame (includes case)	$19.18
V2756	Eye glass case	$0.00
Deluxe and safety frames must be billed with modifier KX. Visual necessity must be documented in the patient’s file. Use modifier NU to identify new frame. Use modifier RA to identify replacement of frame.
V2025	Deluxe frame (includes case)	$25.98
S0516	Safety eyeglass frame	$25.98
Repair and Refitting. See VSP California Medicaid Client Details page.
92370	Repair and refitting spectacles; except for aphakia	$5.67
92371	Repair and refitting spectacles prosthesis for aphakia	$5.67

Using Private Labs

Frames

Frames:Use modifier NU to identify new frame. Use modifier RA to identify replacement of frame. See client detail pages.
V2020	Frame (includes case)	$19.18
V2756	Eye glass case	$0.00
Deluxe and safety frames must be billed with modifier KX. Visual necessity must be documented in the patient’s file. Use modifier NU to identify new frame. Use modifier RA to identify replacement of frame.
V2025	Deluxe frame (includes case)	$25.98
S0516	Safety eyeglass frame	$25.98

Lenses

Use modifier NU to identify new lens(es). Use modifier RA when dispensing and replacing lens. See VSP California Medicaid Client Details page.


Single Vision Lenses, per lens:
V2100	Sphere, plano to ± 4.00d	$16.47
V2101	Sphere, ± 4.12 to ± 7.00d	$19.52
V2102	Sphere, ± 7.12 to ± 20.00d	$23.18
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$16.63
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$16.76
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$26.45
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$28.03
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$19.70
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$19.96
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$29.71
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$33.61
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$23.17
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$23.17
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$33.66
V2114	Spherocylinder, sphere over ± 12.00d	$26.91
V2115	Lenticular, myodisc	$69.35
V2121	Lenticular	$58.29
V2199	Not otherwise classified; single vision lens	Submit invoice for pricing*
Single Vision Dispensing Services:
92340	Fitting of spectacles, except for aphakia, monofocal other than bifocal, per pair	$19.39
92352	Fitting of spectacles, prosthesis for aphakia, monofocal, per pair	$19.39
Bifocal Lenses, per lens:
V2200	Sphere, plano to ± 4.00d	$26.45
V2201	Sphere, ± 4.12 to ± 7.00d	$32.74
V2202	Sphere, ± 7.12 to ± 20.00d	$38.34
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$26.78
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$26.79
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$39.52
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$39.75
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$32.77
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$34.63
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$44.83
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$46.48
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$38.08
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$38.34
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$47.13
V2214	Spherocylinder, sphere over ± 12.00d	$40.38
V2215	Lenticular, myodisc	$86.30
V2220	Add over 3.25d	$12.88
V2221	Lenticular	$68.00
V2299	Specialty bifocal	Submit invoice for pricing*
Bifocal Dispensing Services:
92341	Fitting of spectacles, except for aphakia, bifocal, per pair	$28.62
92353	Fitting of spectacles, prosthesis for aphakia, multifocal, per pair	$28.62
Trifocal Lenses, per lens: Only patients currently wearing trifocal lenses are covered. Document in the patient’s medical record that the patient is currently wearing trifocals. Modifiers KX and RA must be used when replacing trifocal lens(es). See VSP California Medicaid Client Details page.
V2300	Sphere, plano to ± 4.00d	$38.12
V2301	Sphere, ± 4.12 to ± 7.00d	$41.78
V2302	Sphere, ± 7.12 to ± 20.00d	$48.90
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$38.33
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder	$45.19
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$49.59
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$49.82
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$42.84
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$42.84
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$55.65
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$55.88
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$48.90
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$49.13
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$55.88
V2314	Spherocylinder, sphere over ± 12.00d	$48.90
V2320	Add over 3.25d	$12.88
V2321	Lenticular	$84.19
V2399	Specialty trifocal	Submit invoice for pricing*
Trifocal Dispensing Services:
92342	Fitting of spectacles, except for aphakia, multifocal other than bifocal, per pair	$39.38
Variable Lenses, per lens: Use modifier NU to identify new lens(es). Use modifier RA when replacing a lens(es). All alpha modifiers must be billed in upper case. See VSP California Medicaid Client Details page.
V2410	Variable asphericity lens, single vision, full field, glass or plastic	$51.35
V2430	Variable asphericity lens, bifocal, full field, glass or plastic	$87.94
V2499	Variable asphericity lens, other type	Submit invoice for pricing*
Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. Use modifier NU to identify new lens(es). Use RA when replacing lens(es). See VSP California Medicaid Client Details page.
V2700	Balance lens is included in the fee for spectacle lens	$0.00
V2702	Deluxe lens feature	Submit invoice for pricing*
V2710	Slab off prism, glass or plastic, per lens	$36.00
V2715	Prism, per lens	$7.35
V2718	Press-on lens , Fresnel prism, per lens	$14.20
V2744	Tint, photochromic, per lens	$8.98
V2745	Addition to lens, tint: any color, solid, gradient, or equal (excludes photochromic)	$5.00
V2750	Antireflective coating	$13.80
V2755	U-V lens	$8.43
V2760	Scratch resistant coating	$12.33
V2761	Mirror coating, any type, solid, gradient or equal, any lens material	$18.00
V2762	Polarization, any lens material	$33.79
V2770	Occluder lens, per lens (cup or clip patch style)	$6.91
V2780	Oversize lens is included in the fee for spectacle lens	$0.00
V2781	Progressive lens	$30.00
V2782	Lens, index, 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate	$25.00
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.0 glass, excludes polycarbonate	$30.00
V2784	Lens, polycarbonate or equal, any index.	$7.00
V2799	Vision item or service, miscellaneous	Submit invoice for pricing*

Visually Necessary Contact Lenses

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. Use modifier NU to identify new contact lens(es), unless otherwise indicated. Use modifier RA when replacing contact lens(es), unless otherwise indicated. See VSP California Medicaid Client Details page.	Maximum allowance per eye
V2500	PMMA, spherical	$59.35
V2501	PMMA, toric or prism ballast	$93.32
V2510	Gas permeable, spherical	$79.78
V2511	Gas permeable, toric, prism ballast	$128.94
V2513	Gas permeable, extended wear	$137.33
V2520	Hydrophilic, spherical	$70.39
V2521	Hydrophilic, toric, or prism ballast	$122.54
V2523	Hydrophilic, extended wear	$101.63
V2599	Other contact lens types Use this code to bill only for bandage contact lenses. See client detail pages for billing instructions. Bill with RT or LT modifier in addition to NU or RA and KX as instructed as above.	$54.14
V2799	Vision service, miscellaneous For specialty contact lenses that don’t meet a HCPCS definition, use V2799 and modifier NU or RA as appropriate.	Submit invoice for pricing*
S0500	Disposable contact lens	$70.39
S0512	Daily wear specialty contact lens	$122.54
S0514	Color contact lens	$59.35
Visually Necessary Contact Lens Fitting and Dispensing In addition to the basic eye examination, a contact lens examination is reimbursable with CPT codes 92310 – 92312 for recipients with visually necessary conditions. Bill with modifier 22 or SC and modifier KX. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$101.93
92310	Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$32.76
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye.	$32.76
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes.	$32.76

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. Use modifier NU to identify new materials. Use modifier RA when replacing materials.
V2600	Hand held, nonspectacle mounted	Submit invoice for pricing*
V2610	Single lens spectacle mounted	Submit invoice for pricing*
V2615	Telescopic and other compound lens systems, including distance vision,	Submit invoice for pricing*
92499	Unlisted ophthalmological service or procedure Use this code to bill for low vision exams. See client detail pages for billing instructions.	$74.36

Illinois Professional Fee Schedule for Routine Services (IL)

Effective 4/1/2022

Exam Services

92002	Intermediate exam, new patient	$34.76
92004	Comprehensive exam, new patient	$40.00
92012	Intermediate exam, established patient	$30.62
92014	Comprehensive exam, established patient	$40.00
92015	Determination of refractive state	$10.00

Dispensing and Material Services

Frame:

V2020

Frame (includes case)

$20.00

V2025

Deluxe frame

VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

$35.00


Dispensing:
92340	Fitting of spectacles, except for aphakia; monofocal	$20.24
92341	Fitting of spectacles, except for aphakia; bifocal	$28.14


Single Vision Lenses, per lens:
V2100	Sphere, plano to ± 4.00d	$6.38
V2101	Sphere, ± 4.12 to ± 7.00d	$6.38
V2102	Sphere, ± 7.12 to ± 20.00d	$10.21
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$10.21
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$10.21
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$10.21
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$10.21
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2114	Spherocylinder, sphere over ± 12.00d	$10.21
V2115	Lenticular, myodisc	$19.00
V2121	Lenticular lens, single	$19.00
V2199	Specialty single vision VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*


Bifocal Lenses, per lens:
V2200	Sphere, plano to ± 4.00d	$12.43
V2201	Sphere, ± 4.12 to ± 7.00d	$12.43
V2202	Sphere, ± 7.12 to ± 20.00d	$17.20
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$17.20
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$17.20
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$17.20
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$17.20
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2214	Spherocylinder, sphere over ± 12.00d	$17.20
V2215	Lenticular, myodisc	$28.30
V2221	Lenticular lens, bifocal	$28.30
V2299	Specialty bifocal VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*


Variable Asphericity Lenses, per lens:
V2410	Variable asphericity lens, single vision, full field, glass or plastic	$14.50
V2430	Variable asphericity lens, bifocal, full field, glass or plastic	$24.50


Miscellaneous Covered Options and Services, per lens:
V2700	Balance lens	$6.38
V2710	Slab off, glass or plastic	$30.45
V2715	Prism	$2.71
V2730	Special base curve, glass or plastic	$13.03
V2756	Frame case included in the reimbursement for frame	$0.00
V2784	Lens, polycarbonate or equal, any index	$6.43
Miscellaneous Covered Options and Services, per lens: VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
V2762	Polarization	$29.97
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate	$32.37
V2797	Vision supply, accessory and/or service component of another HCPCS vision code	Submit invoice for pricing*
V2799	Miscellaneous vision service	Submit invoice for pricing*

Repair Services

Repair and refitting codes cannot be billed with dispensing and/or material HCPCS codes (e.g., V2020) on the same date of service.
92370	Repair and refitting spectacles; except for aphakia	$4.63

Visually Necessary Contact Lenses

Visually Necessary Contact Lens Fitting and Dispensing VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$125.12
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$100.32
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye	$103.11
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes	$118.62
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$96.80
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$84.69
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye	$78.17
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$97.01
92317	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens	$81.99


Visually Necessary Contact Lenses: VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$92.01
V2501	PMMA, toric or prism ballast	$122.68
V2520	Hydrophilic, spherical	$122.25
V2531	Scleral, gas permeable	$544.58
V2599	Contact lens, other type	Submit invoice for pricing*

Low Vision Services

VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92354	Fitting of spectacle mounted low vision aid; single element system	$12.50
92355	Fitting of spectacle mounted low vision aid; telescopic or other compound lens system	$19.60
V2600	Hand held low vision and other nonspectacle mounted aids	Submit invoice for pricing*

Vision Therapy

VSP Illinois Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report	$60.86
92065	Orthoptic training; performed by a physician or other qualified health care professional	$50.97

*Please refer to the Contacting VSP by Mail section in the VSP Manual.

Michigan Medicaid Plan Professional Fee Schedule for Routine Services (MI)

Effective 7/1/2018

Reimbursement for routine vision care services is based on the lesser of the billed amount or the maximum allowable as reflected on this fee schedule. Fees are subject to change with notification from VSP.

Exam Services

S0620	Ophthalmological exam including refraction, new patient	$46.75
S0621	Ophthalmological exam including refraction, established patient.	$49.13
Procedure codes 92002, 92004, 92012, 92014, and 92015 are covered for Medicare patients only. See VSP Michigan Medicaid Client Detail pages Coordination of Benefits Medicare.
92002	Intermediate exam, new patient	$37.40
92004	Comprehensive exam, new patient	$39.78
92012	Intermediate exam, established patient	$37.40
92014	Comprehensive exam, established patient	$39.78
92015	Determination of refractive state	$9.35

Frame

V2020	Frame (includes case)	$31.90
V2756	Eye glass case	$0.00

Dispensing

92340	Fitting of spectacles, except for aphakia; monofocal	$19.81
92341	Fitting of spectacles, except for aphakia; bifocal	$22.58
92342	Fitting of spectacles, except for aphakia; multifocal, other than bifocal	$24.37
92352	Fitting of spectacle prosthesis for aphakia; monofocal	$22.58
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$26.35

Spectacle Services

Single Vision Lenses, per lens: Use modifier U1 to identify polycarbonate lenses Use modifier U2 to identify high-index lenses
V2100	Sphere, plano to ± 4.00D	$4.80
V2100 - U1	Sphere, plano to ± 4.00D	$8.64
V2101	Sphere, plano to ± 4.12 to 7.00 D	$5.57
V2101 - U1	Sphere, plano to ± 4.12 to 7.00 D	$9.72
V2102	Sphere, plano to ± 7.12 to 20.00 D	$8.41
V2102 - U1	Sphere, plano to ± 7.12 to 20.00 D	$10.26
V2102 - U2	Sphere, plano to ± 7.12 to 20.00 D	$13.50
V2103	Spherocylinder, plano to ± 4.00D, sphere, .12 to 2.00D cylinder	$4.91
V2103 - U1	Spherocylinder, plano to ± 4.00D, sphere, .12 to 2.00D cylinder	$8.85
V2104	Spherocylinder, plano to ± 4.00D, sphere, 2.12 to 4.00D cylinder	$7.07
V2104 - U1	Spherocylinder, plano to ± 4.00D, sphere, 2.12 to 4.00D cylinder	$10.12
V2105	Spherocylinder, plano to ± 4.00D, sphere, 4.25 to 6.00D cylinder	$7.95
V2105 - U1	Spherocylinder, plano to ± 4.00D, sphere, 4.25 to 6.00D cylinder	$10.26
V2106	Spherocylinder, plano to ± 4.00D, sphere, over 6.00D cylinder	$8.11
V2106 - U1	Spherocylinder, plano to ± 4.00D, sphere, over 6.00D cylinder	$10.81
V2107	Spherocylinder, plano to ± 4.25 to 7.00D sphere, .12 to 2.00D cylinder	$5.60
V2107 - U1	Spherocylinder, plano to ± 4.25 to 7.00D sphere, .12 to 2.00D cylinder	$9.75
V2108	Spherocylinder, plano to ± 4.25 to 7.00D sphere, 2.12 to 4.00D cylinder	$7.50
V2108 - U1	Spherocylinder, plano to ± 4.25 to 7.00D sphere, 2.12 to 4.00D cylinder	$10.61
V2109	Spherocylinder, plano to ± 4.25 to 7.00D sphere, 4.25 to 6.00D cylinder	$8.14
V2109 - U1	Spherocylinder, plano to ± 4.25 to 7.00D sphere, 4.25 to 6.00D cylinder	$9.47
V2110	Spherocylinder, plano to ± 4.25 to 7.00D sphere, over 6.00D cylinder	$8.12
V2110 - U1	Spherocylinder, plano to ± 4.25 to 7.00D sphere, over 6.00D cylinder	$11.22
V2111	Spherocylinder, plano to ± 7.25 to 12.00D sphere, .25 to 2.25d cylinder	$8.09
V2111 - U1	Spherocylinder, plano to ± 7.25 to 12.00D sphere, .25 to 2.25d cylinder	$10.67
V2111 - U2	Spherocylinder, plano to ± 7.25 to 12.00D sphere, .25 to 2.25d cylinder	$13.81
V2112	Spherocylinder, plano to ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$8.36
V2112 - U1	Spherocylinder, plano to ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$10.19
V2112 - U2	Spherocylinder, plano to ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$13.81
V2113	Spherocylinder, plano to ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$8.75
V2113 - U1	Spherocylinder, plano to ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$10.26
V2113 - U2	Spherocylinder, plano to ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$15.80
V2114	Spherocylinder, sphere over ± 12.00D	$7.01
V2114 - U1	Spherocylinder, sphere over ± 12.00D	$10.97
V2114 - U2	Spherocylinder, sphere over ± 12.00D	$17.05
V2115	Lenticular, myodisc	$14.69
V2121	Lenticular, single vision	$19.94
V2199	Not otherwise classified single vision lens Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*


Bifocal Lenses, per lens: Use modifier U1 to identify polycarbonate lenses Use modifier U2 to identify high-index lenses
V2200	Sphere, plano to ± 4.00D	$6.73
V2200 - U1	Sphere, plano to ± 4.00D	$11.77
V2201	Sphere, ± 4.12 to 7.00D	$7.80
V2201 - U1	Sphere, ± 4.12 to 7.00D	$11.73
V2202	Sphere, ± 7.12 to 20.00D	$9.18
V2202 - U1	Sphere, ± 7.12 to 20.00D	$14.53
V2202 - U2	Sphere, ± 7.12 to 20.00D	$19.56
V2203	Spherocylinder, plano to ± 4.00D sphere, .12 to 2.00D cylinder	$7.73
V2203 - U1	Spherocylinder, plano to ± 4.00D sphere, .12 to 2.00D cylinder	$11.50
V2204	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$7.82
V2204 - U1	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$11.09
V2205	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$7.98
V2205 - U1	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$11.64
V2206	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$7.97
V2206 - U1	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$11.79
V2207	Spherocylinder, ± 4.25 to 7.00D sphere, .12 to 2.00D cylinder	$7.80
V2207 - U1	Spherocylinder, ± 4.25 to 7.00D sphere, .12 to 2.00D cylinder	$11.79
V2208	Spherocylinder, ± 4.25 to 7.00D sphere, 2.12 to 4.00D cylinder	$7.89
V2208 - U1	Spherocylinder, ± 4.25 to 7.00D sphere, 2.12 to 4.00D cylinder	$10.89
V2209	Spherocylinder, ± 4.25 to 7.00D sphere, 4.25 to 6.00D cylinder	$7.83
V2209 - U1	Spherocylinder, ± 4.25 to 7.00D sphere, 4.25 to 6.00D cylinder	$8.63
V2210	Spherocylinder, ± 4.25 to 7.00D sphere, over 6.00D cylinder	$7.70
V2210 - U1	Spherocylinder, ± 4.25 to 7.00D sphere, over 6.00D cylinder	$8.67
V2211	Spherocylinder, ± 7.25 to 12.00D sphere, .25 to 2.25Dcylinder	$7.87
V2211 - U1	Spherocylinder, ± 7.25 to 12.00D sphere, .25 to 2.25Dcylinder	$16.08
V2211 - U2	Spherocylinder, ± 7.25 to 12.00D sphere, .25 to 2.25Dcylinder	$20.30
V2212	Spherocylinder, ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$8.03
V2212 - U1	Spherocylinder, ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$11.64
V2212 - U2	Spherocylinder, ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$25.13
V2213	Spherocylinder, ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$7.73
V2213 - U1	Spherocylinder, ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$13.14
V2213 - U2	Spherocylinder, ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$32.52
V2214	Spherocylinder, over ± 12.00D	$8.00
V2214 - U1	Spherocylinder, over ± 12.00D	$12.00
V2214 - U2	Spherocylinder, over ± 12.00D	$33.55
V2219	Bifocal seg width over 28mm	$2.88
V2220	Bifocal add over 3.25D	$2.88
V2221	Lenticular, bifocal	$15.00
V2299	Specialty bifocal Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*


Trifocal Lenses, per lens:
V2300	Sphere, plano to ± 4.00D	$9.32
V2301	Sphere, ± 4.12 to 7.00D	$8.97
V2302	Sphere, ± 4.12 to 7.00D	$6.60
V2303	Spherocylinder, plano to ± 4.00D sphere, .12 to 2.00D cylinder	$9.16
V2304	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$9.16
V2305	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D	$8.90
V2306	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$9.24
V2307	Spherocylinder, ± 4.25 to 7.00D sphere, .12 to 2.00D cylinder	$9.24
V2308	Spherocylinder, ± 4.25 to 7.00D sphere, 2.12 to 4.00D cylinder	$9.54
V2309	Spherocylinder, ± 4.25 to 7.00D sphere, 4.25 to 6.00D cylinder	$6.60
V2310	Spherocylinder, ± 4.25 to 7.00D sphere, over 6.00D cylinder	Submit invoice for pricing*
V2311	Spherocylinder, ± 7.25 to 12.00D sphere, .25 to 2.25D cylinder	$10.77
V2312	Spherocylinder, ± 7.25 to 12.00D sphere, 2.25 to 4.00D cylinder	$11.01
V2313	Spherocylinder, ± 7.25 to 12.00D sphere, 4.25 to 6.00D cylinder	$6.60
V2314	Spherocylinder, over ± 12.00D	$6.60
V2320	Trifocal add over 3.25D	$2.88
V2399	Specialty trifocal Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*


Variable Asphericity Lenses, per lens:
V2410	Variable asphericity lens, single vision, full field, glass or plastic	$16.41
V2430	Variable asphericity lens, bifocal, full field, glass or plastic	$18.30
V2499	Variable asphericity lens, other type Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*

Miscellaneous Covered Options and Services, per lens:

V2700	Balance lens	Submit invoice for pricing*
V2710	Slab off	$44.79
V2715	Prism	$2.55
V2718	Press-on lens, Fresnel prism	$2.55
V2782	Index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate is included in the fee for spectacle lens	$0.00
V2784	polycarbonate or equal, any index is included in the fee for spectacle lens	$0.00
S0581	Non-standard lens (use this code plus the appropriate lens code to initiate industrial thickness lenses)	$1.92
Miscellaneous Covered Options and Services, per lens: Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2744	Photochromic	$6.67
V2745	Addition to lens, tint	$1.50
V2755	UV lens	$4.00
V2799	Vision item or service, miscellaneous	Submit invoice for pricing*

Repair and Refitting

92370	Repair and refitting spectacles; except for aphakia	$17.23
92371	Repair and refitting spectacles; spectacle prosthesis for aphakia	$6.54

Visually Necessary Contact Lenses

Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Michigan Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.		Maximum allowance per eye
V2500	Contact lens, PMMA, spherical	Submit invoice for pricing*
V2501	Contact lens, PMMA, toric or prism ballast	Submit invoice for pricing*
V2510	Contact lens, gas permeable, spherical	Submit invoice for pricing*
V2511	Contact lens, gas permeable, toric or prism ballast	Submit invoice for pricing*
V2520	Contact lens, hydrophilic, spherical	Submit invoice for pricing*
V2521	Contact lens, hydrophilic, toric or prism ballast	Submit invoice for pricing*
V2531	Contact lens, scleral, gas permeable	Submit invoice for pricing*
V2599	Contact lens, other type	Submit invoice for pricing*

Visually Necessary Contact Lens Fitting and Dispensing

Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Michigan Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$74.88
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes except for aphakia	$53.49
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye	$56.26
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$65.57
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$54.28
92326	Replacement of contact lens	$30.00

Comprehensive Contact Lens Evaluation

Comprehensive contact lens evaluation is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Michigan Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

S0592

Comprehensive contact lens evaluation

Note: Code S0592 may not be billed with any other procedure code. Use this code when this is the only service performed.

$28.72

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92081	Visual field exam, with interpretation and report; limited	$18.82
92082	Visual field exam, with interpretation and report; intermediate	$26.74
92083	Visual field exam, with interpretation and report; extended	$35.86
99205	Office visit, new, level 5,	$115.10
99215	Office visit, established, level 5	$80.82
V2600	Hand held low vision aids and other non-spectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*
V2615	Telescopic and other compound lens systems, including distance vision, telescopic	Submit invoice for pricing*

Vision Therapy

Vision Therapy services must be billed with modifier KX. See VSP Michigan Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor exam with multiple measurements of ocular deviation. See VSP Michigan Medicaid Client Detail pages for covered conditions.	$36.25
92065	Orthoptic training; performed by a physician or other qualified health care professional See VSP Michigan Medicaid Client Detail pages for qualifying training sessions.	$29.72
92499	Unlisted ophthalmological service or procedure; use for vision therapy training aid.	Submit invoice for pricing*

* Please refer to the Contacting VSP by Mail section of the VSP Manual.

Nevada Professional Fee Schedule For Routine Services (NV)

Effective 1/1/2022

Exam Services

92002	Intermediate exam, new patient	$48.50
92004	Comprehensive exam, new patient	$60.00
92012	Intermediate exam, established patient	$48.50
92014	Comprehensive exam, established patient	$60.00
92015	Determination of refractive state	$15.00

Dispensing and Material Services

Frame:
V2020	Frame (includes case)	$70.00
Dispensing:
92340	Fitting of spectacles, except for aphakia; monofocal	$31.42
92341	Fitting of spectacles, except for aphakia; bifocal	$35.73
92342	Fitting of spectacles, except for aphakia; multifocal	$38.53
92352	Fitting of spectacles, prosthesis for aphakia, monofocal	$31.42
92353	Fitting of spectacles, prosthesis for aphakia, multifocal	$35.73
Single Vision Lenses, per lens:
V2100	Sphere, plano to ± 4.00d	$6.38
V2101	Sphere, ± 4.12 to ± 7.00d	$6.38
V2102	Sphere, ± 7.12 to ± 20.00d	$10.21
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$10.21
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$10.21
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$10.21
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$10.21
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2114	Spherocylinder, sphere over ± 12.00d	$10.21
V2115	Lenticular, myodisc	$19.00
V2118	Lens, aniseikonic single	$19.00
V2121	Lenticular lens, single	$19.00
V2199	Specialty single vision Service must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*
Bifocal Lenses, per lens:
V2200	Sphere, plano to ± 4.00d	$12.43
V2201	Sphere, ± 4.12 to ± 7.00d	$12.43
V2202	Sphere, ± 7.12 to ± 20.00d	$17.20
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$17.20
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$17.20
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$17.20
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$17.20
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2214	Spherocylinder, sphere over ± 12.00d	$17.20
V2215	Lenticular, myodisc	$28.30
V2218	Lens aniseikonic bifocal	$28.30
V2219	Lens bifocal seg width over	$8.00
V2220	Add over 3.25d	$8.00
V2221	Lenticular lens, bifocal	$28.30
V2299	Specialty bifocal Service must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*
Trifocal Lenses, per lens:
V2300	Sphere, plano to ± 4.00d	$18.03
V2301	Sphere, ± 4.12 to ± 7.00d	$18.03
V2302	Sphere, ± 7.12 to ± 20.00d	$22.93
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$18.03
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder	$18.03
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$22.93
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$22.93
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$18.03
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$18.03
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$22.93
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$22.93
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$22.93
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$22.93
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$22.93
V2314	Spherocylinder, sphere over ± 12.00d	$22.93
V2315	Lenticular, myodisc	$34.31
V2318	Lens aniseikonic trifocal	$34.31
V2319	Lens trifocal seg width > 28	$12.00
V2320	Add over 3.25d	$12.00
V2321	Lenticular lens, trifocal	$34.31
V2399	Specialty trifocal Service must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*
Variable Asphericity Lenses, per lens:
V2410	Variable asphericity lens, single vision, full field, glass or plastic	$32.00
V2430	Variable asphericity lens, bifocal, full field, glass or plastic	$47.00
V2499	Variable Sphericity Lens, other type Service must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Submit invoice for pricing*
Miscellaneous Covered Options and Services, per lens:
V2700	Balance lens	$6.38
V2710	Slab off, glass or plastic	$30.45
V2715	Prism	$7.36
V2730	Special base curve, glass or plastic	$12.97
V2756	Frame case included in the reimbursement for frame	$0.00
V2760	Scratch resistant coating	$10.14
V2770	Occluder lens	$12.36
The below services must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromic, any lens material)	$5.05
V2755	UV lens	$7.89
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate	$30.01
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate	$33.84
V2784	Lens, polycarbonate or equal, any index	$22.00
V2786	Specialty occupational multifocal lens	$39.00
V2799	Miscellaneous vision service	Submit invoice for pricing*

Repair Services

Repair and refitting codes cannot be billed with dispensing and/or material HCPCS codes (e.g., V2020) on the same date of service.
92370	Repair and refitting spectacles; except for aphakia	$29.09
92371	Repair and refitting spectacles; spectacle prosthesis for aphakia	$10.90

Visually Necessary Contact Lenses

Visually Necessary Contact Lens Fitting and Dispensing Service must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$129.41
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$89.93
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye	$96.55
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes	$108.78
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$92.70
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$74.72
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye	$69.69
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$86.64
92317	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens	$71.68
92325	Modification of contact lens (separate procedure), with medical supervision of adaptation	$39.47
92326	Replacement of contact lens, single or both	$34.03


Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Nevada Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$83.51
V2501	PMMA, toric or prism ballast	$131.34
V2502	PMMA, bifocal	$192.17
V2503	PMMA, color vision deficiency	$133.40
V2510	Gas permeable, spherical	$112.27
V2511	Gas permeable, toric or prism ballast	$181.44
V2512	Gas permeable, bifocal	$210.65
V2513	Gas permeable, extended wear	$193.26
V2520	Hydrophilic, spherical	$99.04
V2521	Hydrophilic, toric or prism ballast	$172.43
V2522	Hydrophilic, bifocal	$223.74
V2523	Hydrophilic, extended wear	$143.00
V2530	Scleral, gas impermeable	$178.86
V2531	Scleral, gas permeable	$426.30
V2599	Contact lens, other type	Submit invoice for pricing*

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92354	Fitting of spectacle mounted low vision aid; single element system	$12.94
92355	Fitting of spectacle mounted low vision aid; telescopic or other compound lens system	$19.74
V2600	Hand held low vision and other nonspectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*

Vision Therapy

Vision Therapy services must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report	$61.79
92065	Orthoptic training; performed by a physician or other qualified health care professional	$50.41

New Hampshire Well Sense Health Plan
Professional Fee Schedule for Routine Services (NH)

effective 5/1/2020

Exam Services

92002	Intermediate exam, new patient	$ 42.35
92004	Comprehensive exam, new patient	$ 77.33
92012	Intermediate exam, established patient	$ 38.87
92014	Comprehensive exam, established patient	$ 60.89
92015	Determination of refractive state	$ 21.84
S0620	Routine ophthalmological examination including refraction; new patient	$ 99.17
S0621	Routine ophthalmological examination including refraction; established patient	$ 82.73

Dispensing and Material Services

92340	Fitting of spectacles, except for aphakia; monofocal	$ 25.78
92341	Fitting of spectacles, except for aphakia; bifocal	$ 33.51
92342	Fitting of spectacles, except for aphakia; multifocal	$ 16.50

Frames

V2020

Frame

$30.93

V2025

Deluxe frame (Medicare COB Only)

See VSP New Hampshire Medicaid Client Details.

Submit Medicare EOB or EOP for pricing*

V2756

Eye glass case

$0.52

Spectacle Lenses

Single Vision Lenses, per lens (Scratch resistant coating included in lens fee):
V2100	Sphere, plano to ± 4.00d	$ 5.98
V2101	Sphere, ± 4.12 to ± 7.00d	$ 7.25
V2102	Sphere, ± 7.12 to ± 20.00d	$ 10.90
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$ 10.92
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$ 9.54
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$ 10.68
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$ 10.92
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$ 8.17
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$ 9.99
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$ 10.64
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$ 10.88
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$ 11.07
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$ 11.29
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$ 13.73
V2114	Spherocylinder, sphere over ± 12.00d	$ 21.09
V2115	Lenticular, myodisc	$ 20.92
V2118	Lens, aniseikonic single	$ 20.92
V2121	Lenticular lens, single	$ 21.72
V2199	Specialty single vision	Submit invoice for pricing*


Bifocal Lenses, per lens (Scratch resistant coating included in lens fee):
V2200	Sphere, plano to ± 4.00d	$ 8.52
V2201	Sphere, ± 4.12 to ± 7.00d	$ 10.84
V2202	Sphere, ± 7.12 to ± 20.00d	$ 15.83
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$ 15.79
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$ 10.97
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$ 11.07
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$ 14.05
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$ 11.01
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$ 11.13
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$ 10.85
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$ 14.90
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$ 11.82
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$ 11.77
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$ 24.68
V2214	Spherocylinder, sphere over ± 12.00d	$ 41.04
V2215	Lenticular, myodisc	$ 34.32
V2218	Lens aniseikonic bifocal	$ 37.41
V2219	Lens bifocal seg width over	$ 7.22
V2220	Add over 3.25d	$ 7.22
V2221	Lenticular lens, bifocal	$ 24.23
V2299	Specialty bifocal	Submit invoice for pricing*


Trifocal Lenses, per lens (Scratch resistant coating included in lens fee): Trifocal lenses are only allowed by the Medicaid Plan when visually necessary. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP New Hampshire Medicaid Client Details .
V2300	Sphere, plano to ± 4.00d	$ 11.87
V2301	Sphere, ± 4.12 to ± 7.00d	$ 12.46
V2302	Sphere, ± 7.12 to ± 20.00d	$ 21.95
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$ 12.18
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder	$ 12.22
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$ 12.79
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$ 20.49
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$ 21.04
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$ 20.13
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$ 20.23
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$ 20.23
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$ 22.36
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$ 22.36
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$ 22.36
V2314	Spherocylinder, sphere over ± 12.00d	$ 22.36
V2315	Lenticular, myodisc	$ 33.81
V2318	Lens aniseikonic trifocal	$ 33.81
V2319	Lens trifocal seg width > 28	$ 4.64
V2320	Add over 3.25d	$ 4.64
V2321	Lenticular lens, trifocal	$ 9.06
V2399	Specialty trifocal	Submit invoice for pricing*


Variable Asphericity Lenses, per lens (Scratch resistant coating included in lens fee):
V2410	Variable asphericity lens; single vision, full field, glass or plastic	$ 35.35
V2430	Variable asphericity lens; bifocal, full field, glass or plastic	$ 35.35
V2499	Variable asphericity lens; other type	Submit invoice for pricing*


Miscellaneous Covered Options and Services, per lens:
V2700	Balance lens	$ 5.16
V2710	Slab off prism, glass or plastic	$ 29.35
V2715	Prism	$ 2.58
V2718	Press-on lens, Fresnell prism	$ 18.12
V2730	Special base curve, glass or plastic	$ 5.16
V2760	Scratch resistant coating is included in the fee for spectacle lens	$ 0.00
V2784	Lens, polycarbonate or equal, any index	$ 3.09
Miscellaneous Covered Options and Services, per lens: Service must be billed with modifier KX. See VSP New Hampshire Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
V2744	Tint, photochromic	$ 27.27
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromic, any lens material)	$ 5.16
V2750	Antireflective coating	$ 10.31
V2755	UV lens	$ 5.16
V2762	Polarization, any lens material	$ 18.03
V2770	Occluder lens	$ 5.16
V2781	Progressive lens	Submit invoice for pricing*
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate	$ 18.03
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate	$ 18.03
V2799	Miscellaneous vision service	Submit invoice for pricing*

Repair and Refitting

92370

Repair and refitting spectacles, except aphakia

$ 15.47

Visually Necessary Contact Lenses

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP New Hampshire Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.			Maximum allowance per eye
V2500	PMMA, spherical	$100.00
V2501	PMMA, toric or prism ballast	$150.00
V2502	PMMA, bifocal	$150.00
V2503	PMMA, color vision deficiency	$100.00
V2510	Gas permeable, spherical	$100.00
V2511	Gas permeable, toric or prism ballast	$150.00
V2512	Gas permeable, bifocal	$150.00
V2513	Gas permeable, extended wear	$150.00
V2520	Hydrophilic, spherical	$100.00
V2521	Hydrophilic, toric or prism ballast	$150.00
V2522	Hydrophilic, bifocal	$150.00
V2523	Hydrophilic, extended wear	$150.00
V2530	Scleral	$164.63
V2531	Scleral, gas permeable	$309.14
V2599	Contact lens, other type	Submit invoice for pricing*


Visually Necessary Contact Lens Fitting and Dispensing Contacts lens fitting is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP New Hampshire Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$ 53.99
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$ 25.78
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye	$ 43.30
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes	$ 49.49
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$ 37.12
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$ 40.18
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye	$ 27.84
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$ 34.02
92317	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens	$ 18.56
92325	Modification of contact lens (separate procedure), with medical supervision of adaptation	$ 9.49
92326	Replacement of contact lens, single or both; maximum two units	$ 30.19

Vision Therapy

92060

Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report

$ 21.65

* Please refer to the Contacting VSP by Mail section of the VSP Manual.

New York Professional Fee Schedule for Routine Services (NY)

Effective 1/1/14

Note: S0580 (Polycarbonate add-on, per lens) is a temporary HCPCS code. The “Calculate HCPCS and Continue” button on eClaim does not populate these temporary codes. To ensure correct payment, please manually enter S0580 when billing for these services.

Exam Services

92002	Intermediate exam, new patient	$50.00
92004	Comprehensive exam, new patient	$65.00
92012	Intermediate exam, established patient	$45.00
92014	Comprehensive exam, established patient	$60.00
92015	Refraction is included in the fee for the exam service	$0.00

Dispensing and Material Services

92340	Fitting of spectacles, except for aphakia; monofocal	$19.00
92341	Fitting of spectacles, except for aphakia; bifocal	$22.00
92342	Fitting of spectacles, except for aphakia; multifocal	$22.00
92352	Fitting of spectacle prosthesis for aphakia; monofocal	$21.00
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$26.00
92370	Repair and refitting spectacles, except aphakia	$5.00
92371	Repair and refitting spectacles, aphakia	$5.00

Frames

V2020

Frames (includes case)

$15.00

V2025

Deluxe frame

Must be billed with modifier KX. See VSP New York Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

$20.00

V2756

Eye glass case

$0.00

Spectacle Lenses

Single Vision Lenses, per lens:
V2100	Sphere, plano to ± 4.00d	$7.38
V2101	Sphere, ± 4.12 to ± 7.00d	$7.38
V2102	Sphere, ± 7.12 to ± 20.00d	$11.21
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$7.38
Single Vision Lenses, per lens:
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$7.38
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$11.21
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$11.21
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$7.38
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$7.38
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$11.21
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$11.21
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$11.21
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$11.21
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$11.21
V2114	Spherocylinder, sphere over ± 12.00d	$11.21
V2115	Lenticular, myodisc	$20.00
V2118	Lens, aniseikonic single	$20.00
V2121	Lenticular lens, single	$20.00


Bifocal Lenses, per lens:
V2200	Sphere, plano to ± 4.00d	$13.43
V2201	Sphere, ± 4.12 to ± 7.00d	$13.43
V2202	Sphere, ± 7.12 to ± 20.00d	$18.20
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$13.43
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$13.43
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$18.20
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$18.20
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$13.43
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$13.43
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$18.20
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$18.20
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$18.20
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$18.20
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$18.20
V2214	Spherocylinder, sphere over ± 12.00d	$18.20
V2215	Lenticular, myodisc	$27.50
V2218	Lens aniseikonic bifocal	$27.50
V2219	Lens bifocal seg width over	$11.00


Trifocal Lenses, per lens: Trifocal lenses are only allowed by the Medicaid Plan when visually necessary. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2300	Sphere, plano to ± 4.00d	$18.53
V2301	Sphere, ± 4.12 to ± 7.00d	$18.53
V2302	Sphere, ± 7.12 to ± 20.00d	$23.43
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$18.53
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder	$18.53
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$23.43
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$23.43
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$18.53
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$18.53
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$23.43
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$23.43
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$23.43
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$23.43
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$23.43
V2314	Spherocylinder, sphere over ± 12.00d	$23.43
V2315	Lenticular, myodisc	$34.81
V2318	Lens aniseikonic trifocal	$34.81
V2319	Lens trifocal seg width > 28	$15.50
V2320	Add over 3.25d	$8.50
V2321	Lenticular lens, trifocal	$34.81
V2399	Specialty trifocal	$23.43
Variable Asphericity Lenses, per lens:
V2410	Single vision, full field, glass or plastic	$24.80
V2430	Bifocal, full field, glass or plastic	$33.50
V2499	Other type	$33.50
Miscellaneous Covered Options and Services, per lens:
V2700	Balance lens	$10.00
V2710	Slab off prism, glass or plastic	$15.00
V2715	Prism	$1.00
V2718	Press-on lens, Fresnell prism	$12.00
V2770	Occluder lens	$1.50
Miscellaneous Covered Options and Services, per lens: Service must be billed with modifier KX. See VSP New York Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
S0580	Polycarbonate lens	$7.00
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromic, any lens material)	$2.00
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate	$25.00
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate	$35.00
V2799	Miscellaneous vision service	Submit invoice for pricing*

Repair and Refitting

92370	Repair and refitting spectacles, except aphakia	$5.00
92371	Repair and refitting spectacles, aphakia	$5.00

Visually Necessary Contact Lenses

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP New York Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file. Modifier RP must be used to indicate the replacement of contact lenses.	Maximum allowance per eye
V2500	PMMA, spherical	$80.00
V2501	PMMA, toric or prism ballast	$95.00
V2502	PMMA, bifocal	$95.00
V2503	PMMA, color vision deficiency	$95.00
V2510	Gas permeable, spherical	$95.00
V2511	Gas permeable, toric or prism ballast	$110.00
V2512	Gas permeable, bifocal	$125.00
V2513	Gas permeable, extended wear	$125.00
V2520	Hydrophilic, spherical	$100.00
V2521	Hydrophilic, toric or prism ballast	$110.00
V2522	Hydrophilic, bifocal	$110.00
V2523	Hydrophilic, extended wear	$125.00
V2530	Scleral, gas impermeable	$125.00
V2599	Contact lens, other type	$125.00
Visually Necessary Contact Lens Fitting and Dispensing: Service must be billed with modifier KX. See VSP New York Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$250.00
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye	$150.00
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes	$250.00
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$125.00
92326	Replacement of contact lens	$65.00

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92002	Intermediate exam, new patient - Bill for low vision exam.	$50.00
92004	Comprehensive exam, new patient - Bill for low vision exam.	$65.00
92012	Intermediate exam, established patient - Bill for low vision exam.	$45.00
92014	Comprehensive exam, established patient - Bill for low vision exam.	$60.00
92354	Fitting of spectacle mounted low vision aid; single element system	$10.00
92355	Fitting of spectacle mounted low vision aid; telescopic or other compound lens system	$10.00
V2600	Hand held low vision and other nonspectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*
V2615	Telescopic and other compound lens systems, including distance	Submit invoice for pricing*

Vision Therapy

Vision Therapy services must be billed with modifier KX. See VSP New York Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report	$15.00
92065	Orthoptic training; performed by a physician or other qualified health care professional	$8.00

Ohio Professional Fee Schedule For Routine Services (OH)

Effective 6/1/14

Exam Services

92002	Intermediate exam, new patient	$46.00
92004	Comprehensive exam, new patient	$57.00
92012	Intermediate exam, established patient	$42.00
92014	Comprehensive exam, established patient	$52.00
92015	Determination of refractive state is included in the fee for the exam	$0.00
Procedure code 92015 is covered for Medicare patients only. See VSP Ohio Medicaid Client Detail pages.
92015	Determination of refractive state (COB only for Medicare patients)	$5.00

Dispensing and Material Services

Dispensing:
92340	Fitting of spectacles, except for aphakia; monofocal	$21.77
92341	Fitting of spectacles, except for aphakia; bifocal	$26.97
92342	Fitting of spectacles, except for aphakia; multifocal	$30.02
Single Vision Lenses, per lens:
V2100	Sphere, plano to ± 4.00d	$6.38
V2101	Sphere, ± 4.12 to ± 7.00d	$6.38
V2102	Sphere, ± 7.12 to ± 20.00d	$10.21
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$10.21
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$10.21
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$10.21
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$10.21
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$10.21
V2114	Spherocylinder, sphere over ± 12.00d	$10.21
V2115	Lenticular, myodisc	$19.00
V2118	Lens, aniseikonic single	$19.00
V2121	Lenticular lens, single	$19.00
V2199	Specialty single vision	$10.21
Bifocal Lenses, per lens:
V2200	Sphere, plano to ± 4.00d	$12.43
V2201	Sphere, ± 4.12 to ± 7.00d	$12.43
V2202	Sphere, ± 7.12 to ± 20.00d	$17.20
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$17.20
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$17.20
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$17.20
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$17.20
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$17.20
V2214	Spherocylinder, sphere over ± 12.00d	$17.20
V2215	Lenticular, myodisc	$28.30
V2218	Lens aniseikonic bifocal	$28.30
V2219	Lens bifocal seg width over	$8.00
V2220	Add over 3.25d	$4.00
V2221	Lenticular lens, bifocal	$28.30
V2299	Specialty bifocal	$17.20
Trifocal Lenses, per lens:
V2300	Sphere, plano to ± 4.00d	$18.03
V2301	Sphere, ± 4.12 to ± 7.00d	$18.03
V2302	Sphere, ± 7.12 to ± 20.00d	$22.93
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$18.03
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder	$18.03
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$22.93
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$22.93
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$18.03
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$18.03
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$22.93
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$22.93
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$22.93
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$22.93
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$22.93
V2314	Spherocylinder, sphere over ± 12.00d	$22.93
V2315	Lenticular, myodisc	$34.31
V2318	Lens aniseikonic trifocal	$34.31
V2319	Lens trifocal seg width > 28	$12.00
V2320	Add over 3.25d	$12.00
V2321	Lenticular lens, trifocal	$34.31
Variable Asphericity Lenses, per lens:
V2410	Variable asphericity lens, single vision, full field, glass or plastic	$30.00
V2430	Variable asphericity lens, bifocal, full field, glass or plastic	$50.00
Miscellaneous Covered Options and Services, per lens:
S0580	Polycarbonate	$15.00
S0581	Nonstandard lens; industrial thickness	$7.00
V2700	Balance lens	$6.10
V2710	Slab off, glass or plastic	$35.00
V2715	Prism	$3.00
V2718	Press-on lens, Fresnell prism	$35.00
V2730	Special base curve, glass or plastic	$8.00
V2760	Scratch resistant coating	$5.00
V2770	Occluder lens	$10.00
Miscellaneous Covered Options and Services, per lens: Service must be billed with modifier KX. See VSP Ohio Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
V2744	Tint, photochromatic	$7.00
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromic, any lens material)	$5.00
V2755	UV lens	$6.00
V2780	Oversize lens	$8.00
V2781	Progressive lens, per lens	$35.00
V2799	Miscellaneous vision service	Submit invoice for pricing*
Frame:
V2020	Frame (includes case)	$25.00
V2756	Eye glass case	$0.00

Visually Necessary Contact Lenses

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Ohio Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$31.06
V2501	PMMA, toric or prism ballast	$51.77
V2502	PMMA, bifocal	$51.77
V2503	PMMA, color vision deficiency	$51.77
V2510	Gas permeable, spherical	$50.22
V2511	Gas permeable, toric or prism ballast	$75.32
V2512	Gas permeable, bifocal	$100.42
V2513	Gas permeable, extended wear	$100.42
V2520	Hydrophilic, spherical	$60.26
V2521	Hydrophilic, toric or prism ballast	$70.30
V2522	Hydrophilic, bifocal	$77.65
V2523	Hydrophilic, extended wear	$97.00
V2530	Scleral, gas impermeable	$62.12
V2599	Contact lens, other type	$100.42
Visually Necessary Contact Lens Fitting and Dispensing Service must be billed with modifier KX. See VSP Ohio Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$77.86
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye	$34.80
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes	$41.24
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$42.80
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$49.33
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye	$19.61
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$27.86
92317	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens	$16.51
92325	Modification of contact lens (separate procedure), with medical supervision of adaptation	$7.37
92326	Replacement of contact lens, single or both	$28.49

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92354	Fitting of spectacle mounted low vision aid; single element system	$54.59
92355	Fitting of spectacle mounted low vision aid; telescopic or other compound lens system	$38.27
V2600	Hand held low vision and other nonspectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*
V2615	Telescopic and other compound lens systems, including distance	Submit invoice for pricing*

Vision Therapy

Vision Therapy services must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report	$19.85
92065	Orthoptic training; performed by a physician or other qualified health care professional	$13.65

Oregon Medicaid Fee Schedules (OR)

Effective 5/1/2019

Exam Services

92002	Intermediate exam, new patient	$49.00
92004	Comprehensive exam, new patient	$65.00
92012	Intermediate exam, established patient	$49.00
92014	Comprehensive exam, established patient	$65.00
92015	Refraction is included in the fee for the exam service	$0.00

Spectacle Services

Spectacle Dispensing, Complete Pair, New or Total Replacement:
92340	Fitting of spectacles, except for aphakia, monofocal	$25.00
92341	Fitting of spectacles, except for aphakia, bifocal	$28.50
92342	Fitting of spectacles, except for aphakia, trifocal	$30.75
92352	Fitting of spectacle prosthesis for aphakia, monofocal	$26.00
92353	Fitting of spectacle prosthesis for aphakia, multifocal	$32.00
Repair and Refitting: See VSP Oregon Medicaid Client Details for requirements.
92370	Dispensing for repair and fitting, except for aphakia	$23.10
92371	Dispensing for repair and fitting, prosthesis for aphakia	$16.61

Frame

V2020

Frame (includes case)

$12.00

V2025

Deluxe Frame

Must be billed with modifier KX. See VSP Oregon Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

$45.00

V2756

Eye glass case

$0.00

Spectacle

Single Vision Lenses, per lens (scratch resistant coating included in lens fee):
V2100	Sphere, plano to ± 4.00D	$9.75
V2101	Sphere, ± 4.12 to ± 7.00D	$9.75
V2102	Sphere, ± 7.12 to ± 20.00D	$12.25
V2103	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$9.75
V2104	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$9.75
V2105	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$12.25
V2106	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$12.25
V2107	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$9.75
V2108	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$9.75
V2109	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$12.25
V2110	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$12.25
V2111	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$12.25
V2112	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$12.25
V2113	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$12.25
V2114	Spherocylinder, sphere over ± 12.00D	$12.25
V2115	Lenticular (myodisc)	$24.25
V2121	Lenticular lens	$24.25
V2199	Specialty single vision	$12.25


Bifocal Lenses, per lens (scratch resistant coating included in lens fee):
V2200	Sphere, plano to ± 4.00D	$11.25
V2201	Sphere, ± 4.12 to ± 7.00D	$11.25
V2202	Sphere, ± 7.12 to ± 20.00D	$13.75
V2203	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$11.25
V2204	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$11.25
V2205	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$13.75
V2206	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$13.75
V2207	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$11.25
V2208	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$11.25
V2209	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$13.75
V2210	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$13.75
V2211	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$13.75
V2212	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$13.75
V2213	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$13.75
V2214	Spherocylinder, sphere over ± 12.00D	$13.75
V2215	Lenticular (myodisc)	$27.75
V2220	Add over 3.25D	$4.00
V2221	Lenticular lens	$27.75
V2299	Specialty bifocal	$13.75


Trifocal Lenses, per lens (scratch resistant coating included in lens fee):
V2300	Sphere, plano to ± 4.00D	$15.25
V2301	Sphere, ± 4.12 to ± 7.00D	$15.25
V2302	Sphere, ± 7.12 to ± 20.00D	$17.75
V2303	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$15.25
V2304	Spherocylinder, plano to ± 4.00D sphere, 2.25 to 4.00D cylinder	$15.25
V2305	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$17.75
V2306	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$17.75
V2307	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$15.25
V2308	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$15.25
V2309	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$17.75
V2310	Spherocylinder, ± 4.25 to ± 7.00dD sphere, over 6.00D cylinder	$17.75
V2311	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$17.75
V2312	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$17.75
V2313	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$17.75
V2314	Spherocylinder, sphere over ± 12.00D	$17.75
V2320	Add over 3.25D	$4.50
V2399	Specialty trifocal	$17.75


Variable Asphericity Lenses, per lens (scratch resistant coating included in lens fee):
V2410	Single vision, full field, glass or plastic	$21.54
V2430	Bifocal full field, glass or plastic	$26.54
V2499	Other type	$26.54

Contact Lenses

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Oregon Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	Contact lens, PMA, spherical	$150.00
V2501	PMMA, toric or prism ballast	$150.00
V2502	PMMA, bifocal	$150.00
V2503	Contact lens, PMMA, color vision deficiency	$150.00
V2510	Contact lens, gas permeable, spherical	$150.00
V2511	Contact lens, gas permeable, toric or prism ballast	$150.00
V2512	Gas permeable, bifocal	$150.00
V2513	Gas permeable, extended wear	$150.00
V2520	Contact lens, hydrophilic, spherical	$150.00
V2521	Contact lens, hydrophilic, toric or prism ballast	$150.00
V2522	Contact lens, hydrophilic, bifocal	$150.00
V2523	Contact lens, hydrophilic, extended wear	$150.00
V2530	Contact lens, scleral, gas impermeable	$150.00
V2531	Contact lens, scleral, gas permeable	$150.00
92325	Modification of contact lens, with medical supervision of adaptation	$26.52


Visually Necessary Contact Lens Fitting and Dispensing Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Oregon Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$85.46
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$60.58
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye	$63.84
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$74.44
92325	Modification of contact lens, with medical supervision of adaptation	$26.52

Miscellaneous

Miscellaneous Covered Options and Services, per lens:
V2710	Slab off prism, glass or plastic	$34.00
V2718	Press-on lens, Fresnel prism	$18.65
Prism, special base curve, scratch resistant coating and tracings are included in the base lens fee.
V2715	Prism	$0.00
V2730	Special base curve, glass or plastic	$0.00
V2760	Scratch resistant coating	$0.00
Miscellaneous Covered Options and Services, per lens: Service must be billed with modifier KX. See VSP Oregon Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
V2744	Photochromic	$10.50
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromic, any lens material)	$7.00
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate	$25.00
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate	$30.00
V2784	Lens, polycarbonate or equal, any index	$15.00

Vision Therapy

Orthoptic Training:

92060

Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report.

$12.00

92065

Orthoptic training; performed by a physician or other qualified health care professional. Service must be billed with modifier KX.

See VSP Oregon Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

$33.02

South Carolina Professional Fee Schedule For Routine Services (SC)

Effective 09/01/14

Exam Services

92002	Intermediate exam, new patient	$50.00
92004	Comprehensive exam, new patient	$63.50
92012	Intermediate exam, established patient	$50.00
92014	Comprehensive exam, established patient	$63.50
92015	Determination of refractive state	$5.00

Dispensing and Material Services

Spectacle Dispensing, complete pair, new or total replacement, in Otis & Piper frame: When billing for replacement, visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements.
V2100-V2199	Fitting of spectacles, except for aphakia, monofocal	$25.00
V2200-V2299	Fitting of spectacles, except for aphakia, bifocal	$25.00
V2300-V2399	Fitting of spectacles, except for aphakia, trifocal	$25.00
V2020	Frame (includes case) You won’t receive separate payment for frame. Frames are supplied by VSPOne Columbus. You’ll receive a combined dispensing fee of $25.00 for lenses and frame. When billing for replacement, visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements.	See above
Single Vision, Bifocal, Trifocal Lenses in Otis & Piper frame: Polycarbonate lenses (V2784) must be provided and are covered.Polycarbonate single vision, bifocal, and trifocal lenses in an Otis & Piper frame include UV and scratch coating. You won’t receive separate payment for lenses.You’ll receive a combined dispensing fee of $25.00 for lenses and frame.


Spectacle Dispensing, complete pair, new or total replacement, in Deluxe frame: New or replacement frames must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements.
V2100-V2199	Fitting of spectacles, except for aphakia, monofocal	$16.00
V2200-V2299	Fitting of spectacles, except for aphakia, bifocal	$21.00
V2300-V2399	Fitting of spectacles, except for aphakia, trifocal	$35.00
V2025	Deluxe frame (includes case) Must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements.	$65.00
V2756	Eye glass case	$0.00
Single Vision, Bifocal, Trifocal Lenses in Deluxe frame, complete pair: Polycarbonate lenses (V2784) must be provided. Must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements.

Lens Replacement

Lens Replacement, Otis & Piper frame:

You won’t receive separate payment for lenses.You’ll receive a combined dispensing fee of $25.00 for lenses and frame.

Lens Replacement, Deluxe frame:

To indicate replacement lenses, bill withmodifier KX. Visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements.


Miscellaneous Covered Lens Enhancements and Services, per lens Reimbursement for balance lens, prism/slab-off prism, special base curve, and specialty occupational multifocal lenses are included in the cost of the base lens. Bill the following lens enhancements with modifier KX. Visual necessity must be documented in the patient’s file. See VSP South Carolina Medicaid Client Details for requirements. See Advantage Network Lens Enhancement Chart for reimbursement.
V2744	Tint, photochromic	See Advantage Network Lens Enhancement Chart for reimbursement.
V2745	Addition to lens, tint, any color, solid, gradient or equal excluding photochromic, any lens material
V2750	Anti-reflective coating
V2755	UV lens
V2760	Scratch-resistant coating
V2761	Mirror coating, any type, solid, gradient, or equal, any lens material
V2762	Polarization, any lens material
V2780	Oversize lens
V2782	Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate
V2783	Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate
V2784	Lens, polycarbonate or equal, any index

Miscellaneous Non-covered Lens Enhancements and Services, per lens

See Advantage Network Lens Enhancement Chart for doctor service fees.

Visually Necessary Contact Lenses

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP South Carolina Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	Contact lens, PMA, spherical	$13.00
V2501	PMMA, toric or prism ballast	$22.00
V2510	Contact lens, gas permeable, spherical	$30.00
V2511	Contact lens, gas permeable, toric or prism ballast	$42.00
V2520	Contact lens, hydrophilic, spherical	$17.00
V2521	Contact lens, hydrophilic, toric or prism ballast	$50.00
V2599	Contact lens, other type	Submit invoice for pricing*


Visually Necessary Contact Lens Fitting and Dispensing: Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP South Carolina Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$69.27
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye	$65.03
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$73.99
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$62.34

Vision Therapy

Vision Therapy services must be billed with modifier KX. Visual necessity must be

documented in the patient’s file.

92060

Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)

$43.46

*Please refer to the Contacting VSP by Mail section of the VSP Manual.

Utah Professional Fee Schedule For Routine Services (UT)

Effective 7/1/2018

Reimbursement for services is based on the lesser of the billed amount or the maximum allowable reimbursement as reflected on this fee schedule. Fees are subject to change with notification from VSP.

Exam Services

92002	Intermediate exam, new patient	$53.00
92004	Comprehensive exam, new patient	$69.00
92012	Intermediate exam, established patient	$53.00
92014	Comprehensive exam, established patient	$69.00
92015	Determination of refractive state is included in the fee for the exam	$0.00

Frames

V2020

Frame (includes case)

$27.61

V2025

Deluxe Frame (includes case)

If a member requires lenticular lenses, deluxe frames will be allowed. Must be billed with modifier KX. See Client Details page for requirements. Visual necessity must be documented in the patient’s file.

$42.00

V2756

Eye glass case

$0.00

Dispensing

92340	Fitting of spectacles, except for aphakia; monofocal	$25.00
92341	Fitting of spectacles, except for aphakia; bifocal	$29.00
92342	Fitting of spectacles, except for aphakia; multifocal other than bifocal	$32.00

Spectacle Services

Single Vision Lenses, per lens:
V2100	Sphere, plano to ± 4.00d	$6.38
V2101	Sphere, plus or minus 4.12 to plus or minus 7.00d	$6.38
V2102	Sphere, plus or minus 7.12 to plus or minus 20.00d	$10.03
V2103	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2104	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2105	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$10.03
V2106	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$10.03
V2107	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$6.38
V2108	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$6.38
V2109	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$10.03
V2110	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$10.03
V2111	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$10.03
V2112	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$10.03
V2113	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$10.03
V2114	Spherocylinder, sphere over ± 12.00d	$10.03
V2121	Lenticular lens	$18.00
V2199	Specialty single vision; not otherwise classified	$10.03
Bifocal Lenses, per lens:
V2200	Sphere, plano to ± 4.00d	$12.43
V2201	Sphere, plus or minus 4.12 to plus or minus 7.00d	$12.43
V2202	Sphere, plus or minus 7.12 to plus or minus 20.00d	$16.58
V2203	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2204	Spherocylinder, plano to ± 4.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2205	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$16.58
V2206	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$16.58
V2207	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$12.43
V2208	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$12.43
V2209	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$16.58
V2210	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$16.58
V2211	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$16.58
V2212	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$16.58
V2213	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$16.58
V2214	Spherocylinder, sphere over ± 12.00d	$16.58
V2221	Lenticular lens	$25.00
V2299	Specialty bifocal	$16.58
Trifocal Lenses, per lens:
V2300	Sphere, plano to ± 4.00d	$18.03
V2301	Sphere, plus or minus 4.12 to plus or minus 7.00d	$18.03
V2302	Sphere, plus or minus 7.12 to plus or minus 20.00d	$22.18
V2303	Spherocylinder, plano to ± 4.00d sphere, 0.12 to 2.00d cylinder	$18.03
V2304	Spherocylinder, plano to ± 4.00d sphere, 2.25 to 4.00d cylinder	$18.03
V2305	Spherocylinder, plano to ± 4.00d sphere, 4.25 to 6.00d cylinder	$22.18
V2306	Spherocylinder, plano to ± 4.00d sphere, over 6.00d cylinder	$22.18
V2307	Spherocylinder, ± 4.25 to ± 7.00d sphere, 0.12 to 2.00d cylinder	$18.03
V2308	Spherocylinder, ± 4.25 to ± 7.00d sphere, 2.12 to 4.00d cylinder	$18.03
V2309	Spherocylinder, ± 4.25 to ± 7.00d sphere, 4.25 to 6.00d cylinder	$22.18
V2310	Spherocylinder, ± 4.25 to ± 7.00d sphere, over 6.00d cylinder	$22.18
V2311	Spherocylinder, ± 7.25 to ± 12.00d sphere, 0.25 to 2.25d cylinder	$22.18
V2312	Spherocylinder, ± 7.25 to ± 12.00d sphere, 2.25 to 4.00d cylinder	$22.18
V2313	Spherocylinder, ± 7.25 to ± 12.00d sphere, 4.25 to 6.00d cylinder	$22.18
V2314	Sphere, over plus or minus 12.00d	$22.18

Miscellaneous

Miscellaneous Covered Options and Services, per lens:
V2700	Balance lens	$6.38
V2710	Slab off prism, glass or plastic	$30.00
V2715	Prism	$6.00

Repair and Refitting

92370	Repair and refitting spectacles; except for aphakia	$8.36
92371	Repair and refitting spectacles; spectacle prosthesis for aphakia	$8.36

Visually Necessary Contact Lens Services

Visually Necessary Contact Lenses: Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See Client Details page for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2502	PMMA, bifocal	$80.00
V2510	Gas permeable, spherical	$85.00
V2512	Gas permeable, bifocal	$96.00
V2520	Hydrophilic, spherical	$61.33
V2522	Hydrophilic, bifocal	$95.00
V2599	Contact lens, other type	Submit invoice for pricing*

Visually Necessary Contact Lens Fitting and Dispensing

Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Utah Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$99.71
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes except for aphakia	$70.94
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for Aphakia, one eye	$74.08
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$86.25
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$70.42
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$58.20
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye	$53.56
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$67.35
92317	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens	$54.89
92325	Modification of contact lens (separate procedure), with medical supervision of adaptation	$29.97
92326	Replacement of contact lens	$24.94

Low Vision Aids

Low Vision Aids are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2600	Hand held low vision aids and other nonspectacle mounted aids	Submit invoice for pricing*

Vision Therapy

Vision Therapy services must be billed with modifier KX. See VSP Utah Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)	$47.61

* Please refer to the Contacting VSP by Mail section of the Provider Reference Manual.

Virginia Professional Fee Schedule For Routine Services (VA)

Effective 7/1/2022

Exam Services

92002	Intermediate exam, new patient	$57.20
92004	Comprehensive exam, new patient	$65.00
92012	Intermediate exam, established patient	$53.30
92014	Comprehensive exam, established patient	$59.80
92015	Determination of refractive state is included in the fee for the exam	$0.00
92015	Determination of refractive state for COB only	$13.00

Dispensing

Dispensing of eyeglasses is included in the payment of the spectacle lenses
92340	Fitting of spectacles, except for aphakia; monofocal	$0.00
92341	Fitting of spectacles, except for aphakia; bifocal	$0.00
92342	Fitting of spectacles, except for aphakia; multifocal, other than bifocal	$0.00
92352	Fitting of spectacle prosthesis for aphakia; monofocal	$0.00
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$0.00

Spectacle Services

Frames (Includes case):
V2020	Frame purchase, includes dispensing	$45.50
V2025	Deluxe frame Must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	$65.00
V2756	Eye glass case	$0.00


Repair and Replacement Services:
V2020	Replacement due to irreparable damage	$45.50
V2020-RP	Repair and parts replacement	$16.25


Single Vision Lenses, per lens
V2100	Sphere, plano to ± 4.00D	$32.50
V2101	Sphere, ± 4.12 to ± 7.00D	$32.50
V2102	Sphere, ± 7.12 to ± 20.00D	$32.50
V2103	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$32.50
V2104	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$32.50
V2105	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$32.50
V2106	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$32.50
V2107	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$32.50
V2108	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$32.50
V2109	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$32.50
V2110	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$32.50
V2111	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$32.50
V2112	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$32.50
V2113	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$32.50
V2114	Spherocylinder, sphere over ± 12.00D	$32.50
V2115	Lenticular, (myodisc)	$32.50
V2118	Aniseikonic lens	$32.50
V2121	Lenticular lens, single	$32.50
V2199	Specialty single vision	$32.50


Bifocal Lenses, per lens
V2200	Sphere, plano to ± 4.00D	$32.50
V2201	Sphere, ± 4.12 to ± 7.00D	$32.50
V2202	Sphere, ± 7.12 to ± 20.00D	$32.50
V2203	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$32.50
V2204	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$32.50
V2205	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$32.50
V2206	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$32.50
V2207	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$32.50
V2208	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$32.50
V2209	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$32.50
V2210	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$32.50
V2211	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$32.50
V2212	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$32.50
V2213	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$32.50
V2214	Spherocylinder, sphere over ± 12.00D	$32.50
V2215	Lenticular (myodisc)	$32.50
V2218	Aniseikonic lens	$32.50
V2219	Seg width over 28mm	$32.50
V2220	Add over 3.25D	$32.50
V2221	Lenticular lens, bifocal	$32.50
V2299	Specialty bifocal	$32.50


Trifocal Lenses, per lens
V2300	Sphere, plano to ± 4.00D	$83.85
V2301	Sphere, ± 4.12 to ± 7.00D	$83.85
V2302	Sphere, ± 7.12 to ± 20.00D	$91.65
V2303	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$83.85
V2304	Spherocylinder, plano to ± 4.00D sphere, 2.25 to 4.00D cylinder	$83.85
V2305	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$91.65
V2306	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$91.65
V2307	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$83.85
V2308	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$83.85
V2309	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$91.65
V2310	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$91.65
V2311	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$91.65
V2312	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$91.65
V2313	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$91.65
V2314	Spherocylinder, sphere over ± 12.00D	$91.65
V2315	Lenticular (myodisc)	$89.70
V2318	Aniseikonic lens	$83.85
V2319	Seg width over 28mm	$13.00
V2320	Add over 3.25D	$11.70
V2321	Lenticular lens, trifocal	$89.70
V2399	Specialty trifocal	$91.65


Variable Asphericity Lenses, per lens:
V2410	Single vision, full field, glass or plastic	$51.16
V2430	Bifocal, full field, glass or plastic	$143.00
V2499	Variable Sphericity Lens, other type	$143.00


Miscellaneous Covered Options and Services, per lens: Ophthalmic lenses may be made of either: (1) plastic with scratch-resistant coating or (2) glass.
V2760	Scratch resistant coating	$5.85
Miscellaneous Covered Options and Services, per lens: Services must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromatic) any lens material	$4.55
V2755	UV lens	$5.85
V2784	Lens, polycarbonate or equal, any index	$9.10


Visually Necessary Contact Lenses Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$130.00
V2501	PMMA, toric or prism ballast	$156.00
V2502	PMMA, bifocal	$182.00
V2503	PMMA, color vision deficiency	$156.00
V2510	Gas permeable, spherical	$130.00
V2511	Gas permeable, toric or prism ballast	$156.00
V2512	Gas permeable, bifocal	$182.00
V2513	Gas permeable, extended wear	$156.00
V2520	Hydrophilic, spherical	$130.00
V2521	Hydrophilic, toric or prism ballast	$156.00
V2522	Hydrophilic, bifocal	$182.00
V2523	Hydrophilic, extended wear	$156.00
V2530	Scleral	$292.50
V2531	Contact lens, scleral, gas permeable	Submit invoice for pricing*
V2599	Not otherwise classified	$195.00


Visually Necessary Contact Lens Fitting and Dispensing Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$156.78
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$82.15
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye	$80.63
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$92.92
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$92.92
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$79.90
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting; corneal lens for aphakia, one eye	$83.94
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$110.90
92326	Replacement of contact lens	$30.39

Please note: Refer to the Client Detail Pages for instructions when billing for elective contact lenses instead of glasses. Reimbursement shall be up to $100.

Vision Therapy

Post Publication Manual Update

The following was omitted from the last print update:

Vision Therapy Services must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

92060

Sensorimotor examination with multiple measurements of ocular deviation.

$48.26

92065

Orthoptic training.

$28.95

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2600	Hand held low vision and other nonspectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*
V2615	Telescopic and other compound lens systems, including distance vision telescopic, near vision	Submit invoice for pricing*

* Please refer to the Contacting VSP by Mail section.

Washington Professional Fee Schedule (WA)

Effective July 1, 2021

Routine Vision Services

Reimbursement for routine vision care services is based on the lesser of the billed amount

or the maximum allowable reimbursement. Fees are subject to change with notification from VSP.

Exam Services

92002	Intermediate exam, new patient	$53.00
92004	Comprehensive exam, new patient	$68.00
92012	Intermediate exam, established patient	$53.00
92014	Comprehensive exam, established patient	$68.00
92015	Determination of refractive state	$10.00

Ordering Vision Hardware

Washington State Health Care Authority’s vision hardware contractor is CI Optical, which is part of the Washington State Department of Correctional Industries. Providers must obtain all hardware through CI Optical. The agency does not pay any other optical manufacturer or provider for frames, lenses, or contact lenses.

Dispensing for Material Services

Single Vision Dispensing Services:
92340	Fitting of spectacles, except for aphakia; monofocal,	$20.78
92352	Fitting of spectacle prosthesis for aphakia; monofocal	$27.34
Bifocal Dispensing Services:
92341	Fitting of spectacles, except for aphakia; bifocal	$23.60
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$31.05
Trifocal Dispensing Services:
92342	Fitting of spectacles, except for aphakia; multifocal other than bifocal	$25.42
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$31.05

Visually Necessary Contact Lens Services

In addition to the routine eye examination, a contact lens examination is reimbursable with CPT codes 92310 – 92313 and 92072 when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Washington Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$77.88
92310	Prescription of optical and physical characteristics of and fitting of contact lenses, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$57.10
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye.	$60.12
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes.	$69.81
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens.	$57.10

Vision Therapy

Vision Therapy services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor examination with multiple measurements of ocular deviation with interpretation and report	$38.33
92065	Orthoptic training; performed by a physician or other qualified health care professional.	$32.08

Low Vision Services


Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file. Aids must be obtained through CI Optical.
92354	Fitting of spectacle mounted low vision aid; single element system	$8.01
92355	Fitting of spectacle mounted low vision aid; telescopic/other compound lens system	$12.50

West Virginia Professional Fee Schedule (WV)

Effective 4/1/2016

Note: Codes S0580 (Polycarbonate add-on, per lens) and S0590 (Integral lens service, miscellaneous) are temporary HCPCS codes. The “Calculate HCPCS and Continue” button on eClaim does not populate these temporary codes. To ensure correct payment, please manually enter S0580 or S0590 when billing for these services.

Exam Services

92002	Intermediate exam, new patient	$54.03
92004	Comprehensive exam, new patient	$99.94
92012	Intermediate exam, established patient	$56.92
92014	Comprehensive exam, established patient	$83.15
92015	Determination of refractive state	$14.16

Dispensing

Dispensing of eyeglasses is included in the payment of the spectacle lenses
92340	Fitting of spectacles, except for aphakia; monofocal	$0.00
92341	Fitting of spectacles, except for aphakia; bifocal	$0.00
92342	Fitting of spectacles, except for aphakia; multifocal, other than bifocal	$0.00
92352	Fitting of spectacle prosthesis for aphakia; monofocal	$0.00
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$0.00

Frames

V2020	Frames (includes case)	$70.00
V2756	Eye glass case	$0.00

Spectacle Services

Single Vision Lens, glass or plastic, per lens:
V2100	Sphere, plano to ± 4.00D	$15.86
V2101	Sphere, ± 4.12 to ± 7.00D	$21.00
V2102	Sphere, ± 7.12 to ± 20.00D	$22.75
V2103	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$21.35
V2104	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$21.35
V2105	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$24.83
V2106	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$26.58
V2107	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$23.08
V2108	Spherocylinder, ± 4.25d to ± 7.00D sphere, 2.12 to 4.00D cylinder	$24.83
V2109	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$26.58
V2110	Spherocylinder, ± 4.25 to ±7.00D sphere, over 6.00D cylinder	$28.33
V2111	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$24.83
V2112	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$26.58
V2113	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$29.75
V2114	Spherocylinder, sphere over ± 12.00D	$33.25
V2115	Lenticular lens, myodisc	$52.50
V2118	Aniseikonic lens, single	$26.58
V2121	Lenticular lens, single	$52.50
V2199	Specialty single vision	$33.25


Bifocal Lens, glass or plastic, per lens:
V2200	Sphere, plano to ± 4.00D	$19.60
V2201	Sphere, ± 4.12 to ± 7.00D	$24.50
V2202	Sphere, ± 7.12 to ± 20.00D	$26.25
V2203	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$24.85
V2204	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$24.85
V2205	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$28.35
V2206	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$30.10
V2207	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$26.60
V2208	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$28.35
V2209	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$30.10
V2210	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$31.85
V2211	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$28.35
V2212	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$30.10
V2213	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$33.25
V2214	Spherocylinder, sphere over ± 12.00D	$36.75
V2215	Lenticular, myodisc	$52.50
V2218	Aniseikonic lens, bifocal	$30.10
V2219	Lens bifocal seg width over 28 mm	$29.00
V2220	Add over 3.25D	$24.00
V2221	Lenticular lens, bifocal	$52.50
V2299	Specialty bifocal	$36.75


Trifocal Lens, glass or plastic, per lens:
V2300	Sphere, plano to ± 4.00D	$23.10
V2301	Sphere, ± 4.12 to ± 7.00D	$28.00
V2302	Sphere, ± 7.12 to ± 20.00D	$29.75
V2303	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$28.35
V2304	Spherocylinder, plano to ± 4.00D sphere, 2.25 to 4.00D cylinder	$30.10
V2305	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$31.85
V2306	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$33.60
V2307	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$30.10
V2308	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$31.85
V2309	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$33.60
V2310	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$35.35
V2311	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$31.85
V2312	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$33.60
V2313	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$36.75
V2314	Spherocylinder, sphere over ± 12.00D	$40.25
V2315	Lenticular, myodisc	$52.50
V2318	Aniseikonic lens, trifocal	$33.60
V2319	Lens trifocal seg width over 28 mm	$34.00
V2320	Add over 3.25D	$29.00
V2321	Lenticular lens, trifocal	$52.50
V2399	Specialty trifocal	$40.25


Variable Asphericity Lens, glass or plastic, per lens:
V2410	Variable asphericity, single vision, full field	$98.00
V2430	Variable asphericity, bifocal, full field	$118.00
V2499	Variable asphericity, other type	$118.00


Miscellaneous Covered Options and Services, per lens:
S0580	Polycarbonate add-on	$13.50
V2700	Balance lens	$21.51
V2710	Slab off prism, glass or plastic	$28.00
V2715	Prism	$10.50
V2718	Press-on lens, Fresnel prism	$17.80
V2730	Special base curve, glass or plastic	$10.50
V2770	Occluder lens	$7.00
V2780	Oversize lens	$5.25
Miscellaneous Covered Options and Services, per lens: Services must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2744	Photochromatic. See West Virginia Medicaid Client Details for required diagnosis codes.	$10.50
V2755	Ultraviolet lens. See West Virginia Medicaid Client Details for covered conditions.	$8.75
V2799	Vision item or service, miscellaneous	Submit invoice for pricing*
S0590	Integral lens service, miscellaneous (reported separately)	$5.00
92499	Unlisted ophthalmological service or procedure	Submit invoice for pricing*


Repair and Refitting:
92370	Repair and refitting of spectacles, except for aphakia	$20.72
92371	Repair and refitting of spectacles for aphakia	$7.34

Contact Lenses

Visually Necessary Contact Lenses Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See V SP West Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$76.05
V2501	PMMA, toric or prism ballast	$115.84
V2502	PMMA, bifocal	$142.70
V2503	PMMA, color vision deficiency	$131.43
V2510	Gas permeable, spherical	$103.81
V2511	Gas permeable, toric, prism ballast	$149.16
V2512	Gas permeable, bifocal	$176.12
V2513	Gas permeable, extended wear	$147.98
V2520	Hydrophilic, spherical	$97.58
V2521	Hydrophilic, toric, or prism ballast	$169.88
V2522	Hydrophilic, bifocal	$165.33
V2523	Hydrophilic, extended wear	$140.89
V2530	Scleral, gas permeable	$208.68
V2599	Not otherwise classified	$169.88


Visually Necessary Contact Lenses Fitting and Dispensing Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP West Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$65.31
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, one eye	$66.89
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, for aphakia, both eyes	$76.59
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$63.21
92314	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens, both eyes, except for aphakia	$52.72
92315	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, one eye	$46.16
92316	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneal lens for aphakia, both eyes	$58.23
92317	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation and direction of fitting by independent technician; corneoscleral lens	$48.53
92325	Modification of contact lens (separate procedure), with medical supervision of adaptation	$25.71
92326	Replacement of contact lens	$21.77

Low Vision Aids

Low Vision Aids are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2600	Hand held low vision aids and other nonspectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*
V2615	Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system	Submit invoice for pricing*

Vision Therapy

Vision Therapy services must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
92060	Sensorimotor evaluation	$43.54
92065	Orthoptic training; performed by a physician or other qualified health care professional.	$33.84

* Please refer to the Contacting VSP by Mail section of the VSP Manual.

Professional Fee Schedule for Routine Services for ages 20 and under Elements (VA)

Effective 7/1/2022

92002	Intermediate exam, new patient	$57.20
92004	Comprehensive exam, new patient	$65.00
92012	Intermediate exam, established patient	$53.30
92014	Comprehensive exam, established patient	$59.80
92015	Determination of refractive state is included in the fee for the exam	$ 0.00
92015	Determination of refractive state for COB only	$13.00

Dispensing and Material Services

Spectacle Dispensing, complete pair, new or total replacement, in Otis & Piper frame: When billing for replacement, visual necessity must be documented in the patient’s file. See VSP Virginia Medicaid Client Details for requirements.
V2100-V2199	Fitting of spectacles, except for aphakia, monofocal	$25.00
V2200-V2299	Fitting of spectacles, except for aphakia, bifocal	$25.00
V2300-V2399	Fitting of spectacles, except for aphakia, trifocal	$25.00
Variable Asphericity Lenses, per pair in Otis & Piper frame:
V2410	Single vision, full field, glass or plastic	$25.00
V2430	Bifocal, full field, glass or plastic	$25.00
V2499	Variable Sphericity Lens, other type	$25.00
V2020	Frame You won’t receive separate payment for frame. Frames are supplied by VSPOne Columbus. You’ll receive a combined dispensing fee of $25.00 for lenses and frame. When billing for replacement, visual necessity must be documented in the patient’s file. See VSP Virginia Medicaid Client Details for requirements.	See above
Single Vision, Bifocal, Trifocal Lenses in Otis & Piper frame: Polycarbonate lenses (V2784) are covered as a standard option for Otis & Piper frame. Polycarbonate single vision, bifocal, and trifocal lenses in an Otis & Piper frame include UV and scratch coating. You won’t receive separate payment for lenses. You’ll receive a combined dispensing fee of $25.00 for lenses and frame.


Spectacle Dispensing, complete pair, new or total replacement, in Deluxe frame: New or replacement frames must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP Virginia Medicaid Client Details for requirements.
Spectacle Dispensing, complete pair, new or total replacement, in Deluxe frame: When billing for replacement, visual necessity must be documented in the patient’s file. See VSP Virginia Medicaid Client Details for requirements.
Repair and Replacement Dispensing. Service must be billed with modifier RP.
V2100-V2199	Fitting of spectacles, except for aphakia, monofocal	$16.00
V2200-V2299	Fitting of spectacles, except for aphakia, bifocal	$21.00
V2300-V2399	Fitting of spectacles, except for aphakia, trifocal	$35.00
V2025	Deluxe frame Must be billed with modifier KX. Visual necessity must be documented in the patient’s file. See VSP Virginia Medicaid Client Details for requirements.	$50.00
Miscellaneous Covered Lens Enhancements and Services, per lens: See Advantage Network Lens Enhancement Chart for reimbursement.
V2760	Scratch resistant coating, per lens	See Advantage Network Lens Enhancement Chart for reimbursement.
Miscellaneous Covered Lens Enhancements and Services, per lens: Reimbursement for balance lens, prism/slab-off prism, special base curve, and specialty occupational multifocal lenses are included in the cost of the base lens. Bill the following lens enhancements with modifier KX. Visual necessity must be documented in the patient’s file. See VSP Virginia Medicaid Client Details for requirements. See Advantage Network Lens Enhancement Chart for reimbursement.
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromatic) any lens material	See Advantage Network Lens Enhancement Chart for reimbursement
V2755	UV lens
V2784	Lens, polycarbonate or equal, any index

Miscellaneous Non-covered Lens Enhancements and Services, per lens

See Advantage Network Lens Enhancement Chart for doctor service fees.


Visually Necessary Contact Lenses Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$130.00
V2501	PMMA, toric or prism ballast	$156.00
V2502	PMMA, bifocal	$182.00
V2503	PMMA, color vision deficiency	$156.00
V2510	Gas permeable, spherical	$130.00
V2511	Gas permeable, toric or prism ballast	$156.00
V2512	Gas permeable, bifocal	$182.00
V2513	Gas permeable, extended wear	$156.00
V2520	Hydrophilic, spherical	$130.00
V2521	Hydrophilic, toric or prism ballast	$156.00
V2522	Hydrophilic, bifocal	$182.00
V2523	Hydrophilic, extended wear	$156.00
V2530	Scleral	$292.50
V2531	Contact lens, scleral, gas permeable	Submit invoice for pricing*
V2599	Not otherwise classified	$195.00
Visually Necessary Contact Lens Fitting and Dispensing Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92070	Fitting of contact lens for management of keratoconus, initial fitting	$156.78
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$82.15
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye	$80.63
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$92.92
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$92.92
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$79.90
92415	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting; corneal lens for aphakia, one eye	$83.94
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$110.90
92326	Replacement of contact lens	$30.39

FAMIS: Refer to the Client Detail pages for instructions when billing for elective contact lenses instead of glasses. Reimbursement shall be up to $100.

Vision Therapy

Vision Therapy Services must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file. Vision Therapy is not covered for Virginia Premier FAMIS.
92060	Sensorimotor examination with multiple measurements of ocular deviation.	$48.26
92065	Orthoptic training; performed by a physician or other qualified health care professional.	$28.95

* Please refer to the Contacting VSP by Mail section of the VSP Manual.

Virginia Professional Fee Schedule For Routine Services 21 And Over (VA)

Effective 5/1/19

Exam Services

92002	Intermediate exam, new patient	$44.00
92004	Comprehensive exam, new patient	$50.00
92012	Intermediate exam, established patient	$41.00
92014	Comprehensive exam, established patient	$46.00
92015	Determination of refractive state is included in the fee for the exam	$0.00
92015	Determination of refractive state for COB only	$10.00

Dispensing

Dispensing of eyeglasses is included in the payment of the spectacle lenses
92340	Fitting of spectacles, except for aphakia; monofocal	$0.00
92341	Fitting of spectacles, except for aphakia; bifocal	$0.00
92342	Fitting of spectacles, except for aphakia; multifocal, other than bifocal	$0.00
92352	Fitting of spectacle prosthesis for aphakia; monofocal	$0.00
92353	Fitting of spectacle prosthesis for aphakia; multifocal	$0.00

Spectacle Services

Frames (Includes case): Refer to VSP Virginia Medicaid Client Details for FAMIS fee schedule.
V2020	Frame purchase, includes dispensing	$35.00
V2025	Deluxe frame Must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	$50.00
V2756	Eye glass case	$0.00


Repair and Replacement Services:
V2020	Replacement due to irreparable damage	$35.00
V2020-RP	Repair and parts replacement	$12.50


Single Vision Lenses, per lens; Refer to VSP Virginia Medicaid Client Details for FAMIS fee schedule.
V2100	Sphere, plano to ± 4.00D	$25.00
V2101	Sphere, ± 4.12 to ± 7.00D	$25.00
V2102	Sphere, ± 7.12 to ± 20.00D	$25.00
V2103	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$25.00
V2104	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$25.00
V2105	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$25.00
V2106	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$25.00
V2107	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$25.00
V2108	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$25.00
V2109	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$25.00
V2110	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$25.00
V2111	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$25.00
V2112	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$25.00
V2113	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$25.00
V2114	Spherocylinder, sphere over ± 12.00D	$25.00
V2115	Lenticular, (myodisc)	$25.00
V2118	Aniseikonic lens	$25.00
V2121	Lenticular lens, single	$25.00
V2199	Specialty single vision	$25.00


Bifocal Lenses, per lens; Refer to Virginia Medicaid Client Details for FAMIS fee schedule.
V2200	Sphere, plano to ± 4.00D	$25.00
V2201	Sphere, ± 4.12 to ± 7.00D	$25.00
V2202	Sphere, ± 7.12 to ± 20.00D	$25.00
V2203	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$25.00
V2204	Spherocylinder, plano to ± 4.00D sphere, 2.12 to 4.00D cylinder	$25.00
V2205	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$25.00
V2206	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$25.00
V2207	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$25.00
V2208	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$25.00
V2209	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$25.00
V2210	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$25.00
V2211	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$25.00
V2212	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$25.00
V2213	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$25.00
V2214	Spherocylinder, sphere over ± 12.00D	$25.00
V2215	Lenticular (myodisc)	$25.00
V2218	Aniseikonic lens	$25.00
V2219	Seg width over 28mm	$25.00
V2220	Add over 3.25D	$25.00
V2221	Lenticular lens, bifocal	$25.00
V2299	Specialty bifocal	$25.00


Trifocal Lenses, per lens; Refer to VSP Virginia Medicaid Client Details for FAMIS fee schedule.
V2300	Sphere, plano to ± 4.00D	$64.50
V2301	Sphere, ± 4.12 to ± 7.00D	$64.50
V2302	Sphere, ± 7.12 to ± 20.00D	$70.50
V2303	Spherocylinder, plano to ± 4.00D sphere, 0.12 to 2.00D cylinder	$64.50
V2304	Spherocylinder, plano to ± 4.00D sphere, 2.25 to 4.00D cylinder	$64.50
V2305	Spherocylinder, plano to ± 4.00D sphere, 4.25 to 6.00D cylinder	$70.50
V2306	Spherocylinder, plano to ± 4.00D sphere, over 6.00D cylinder	$70.50
V2307	Spherocylinder, ± 4.25 to ± 7.00D sphere, 0.12 to 2.00D cylinder	$64.50
V2308	Spherocylinder, ± 4.25 to ± 7.00D sphere, 2.12 to 4.00D cylinder	$64.50
V2309	Spherocylinder, ± 4.25 to ± 7.00D sphere, 4.25 to 6.00D cylinder	$70.50
V2310	Spherocylinder, ± 4.25 to ± 7.00D sphere, over 6.00D cylinder	$70.50
V2311	Spherocylinder, ± 7.25 to ± 12.00D sphere, 0.25 to 2.25D cylinder	$70.50
V2312	Spherocylinder, ± 7.25 to ± 12.00D sphere, 2.25 to 4.00D cylinder	$70.50
V2313	Spherocylinder, ± 7.25 to ± 12.00D sphere, 4.25 to 6.00D cylinder	$70.50
V2314	Spherocylinder, sphere over ± 12.00D	$70.50
V2315	Lenticular (myodisc)	$69.00
V2318	Aniseikonic lens	$64.50
V2319	Seg width over 28mm	$10.00
V2320	Add over 3.25D	$9.00
V2321	Lenticular lens, trifocal	$69.00
V2399	Specialty trifocal	$70.50


Variable Asphericity Lenses, per lens:
V2410	Single vision, full field, glass or plastic	$39.35
V2430	Bifocal, full field, glass or plastic	$110.00
V2499	Variable Sphericity Lens, other type	$110.00


Miscellaneous Covered Options and Services, per lens: Ophthalmic lenses may be made of either: (1) plastic with scratch-resistant coating or (2) glass.
V2760	Scratch resistant coating	$4.50
Miscellaneous Covered Options and Services, per lens: Services must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2745	Addition to lens, tint, any color, solid, gradient or equal (excludes photochromatic) any lens material	$3.50
V2755	UV lens	$4.50
V2784	Lens, polycarbonate or equal, any index	$7.00


Visually Necessary Contact Lenses Contacts are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.	Maximum allowance per eye
V2500	PMMA, spherical	$100.00
V2501	PMMA, toric or prism ballast	$120.00
V2502	PMMA, bifocal	$140.00
V2503	PMMA, color vision deficiency	$120.00
V2510	Gas permeable, spherical	$100.00
V2511	Gas permeable, toric or prism ballast	$120.00
V2512	Gas permeable, bifocal	$140.00
V2513	Gas permeable, extended wear	$120.00
V2520	Hydrophilic, spherical	$100.00
V2521	Hydrophilic, toric or prism ballast	$120.00
V2522	Hydrophilic, bifocal	$140.00
V2523	Hydrophilic, extended wear	$120.00
V2530	Scleral	$225.00
V2531	Contact lens, scleral, gas permeable	Submit invoice for pricing*
V2599	Not otherwise classified	$150.00


Visually Necessary Contact Lens Fitting and Dispensing Contact lens fitting and dispensing is only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.
92072	Fitting of contact lens for management of keratoconus, initial fitting	$120.60
92310	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia	$63.19
92311	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye	$63.02
92312	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, both eyes	$71.48
92313	Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens	$71.48
92314	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneoscleral lens, both eyes except for aphakia	$61.46
92315	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting; corneal lens for aphakia, one eye	$64.57
92316	Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes	$85.31
92326	Replacement of contact lens	$23.38

Please note: Refer to the Client Detail Pages for instructions when billing for elective contact lenses instead of glasses. Reimbursement shall be up to $100.

Vision Therapy

Post Publication Manual Update

The following was omitted from the last print update:

Vision Therapy Services must be billed with modifier KX. See VSP Virginia Medicaid Client Details for requirements. Visual necessity must be documented in the patient’s file.

Vision Therapy is not covered for Virginia Premier FAMIS.

92060

Sensorimotor examination with multiple measurements of ocular deviation.

$37.12

92065

Orthoptic training; performed by a physician or other qualified health care professional.

$22.27

Low Vision Services

Low Vision services are only allowed by the Medicaid Plan when visually necessary according to Medicaid’s guidelines. Service must be billed with modifier KX. Visual necessity must be documented in the patient’s file.
V2600	Hand held low vision and other nonspectacle mounted aids	Submit invoice for pricing*
V2610	Single lens spectacle mounted low vision aids	Submit invoice for pricing*
V2615	Telescopic and other compound lens systems, including distance vision telescopic, near vision	Submit invoice for pricing*

* Please refer to the Contacting VSP by Mail section.

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medicaid plan Table of content

VSP’s Medicaid Plan

Enrollment/Doctor Participation

Exam Coverage

Materials Coverage

Laboratory

Submitting Claims/Billing, Reimbursement, & Appeals

Medicaid Client Details

Medicaid Fee Schedules

VSP’s Medicaid Plan

VSP’s Medicaid Plan (AZ)

VSP’s Medicaid Plan (CA)

VSP’s Medicaid Plan (IL)

VSP’s Medicaid Plan (MI)

VSP’s Medicaid Plan (NV)

VSP’s Medicaid Plan (NH)

VSP’s Medicaid Plan (NY)

VSP’s Medicaid Plan (OH)

VSP’s Medicaid Plan (OR)

VSP’s Medicaid Plan (SC)

VSP’s Medicaid Plan (UT)

VSP’s Medicaid Plan (VA)

VSP’s Medicaid Plan (WA)

VSP’s Medicaid Plan (WV)

Enrollment/Doctor Participation

Enrollment/Doctor Participation (AZ)

Enrollment/Doctor Participation (CA)

Enrollment/Doctor Participation (IL)

Enrollment/Doctor Participation (MI)

Enrollment/Doctor Participation (NV)

Enrollment/Doctor Participation (NH)

Enrollment/Doctor Participation (NY)

Enrollment/Doctor Participation (OH)

Enrollment/Doctor Participation (OR)

Enrollment/Doctor Participation (SC)

Enrollment/Doctor Participation (UT)

Enrollment/Doctor Participation (VA)

Enrollment/Doctor Participation (WA)

Enrollment/Doctor Participation (WV)

Cultural Competence Training (AZ)

Cultural Competence Training (CA)

Cultural Competence Training (IL)

Cultural Competence Training (MI)

Cultural Competence Training (NV)

Cultural Competence Training (NH)

Cultural Competence Training (NY)

Cultural Competence Training (OH)

Cultural Competence Training (OR)

Cultural Competence Training (SC)

Cultural Competence Training (UT)

Cultural Competence Training (VA)

Cultural Competence Training (WA)

Cultural Competence Training (WV)

Eligibility & Authorization (AZ)

Eligibility & Authorization (CA)

Eligibility & Authorization (IL)

Eligibility & Authorization (MI)

Eligibility & Authorization (NV)

Eligibility & Authorization (NH)

Eligibility & Authorization (NY)

Eligibility & Authorization (OH)

Eligibility & Authorization (OR)

Eligibility & Authorization (SC)

Eligibility & Authorization (UT)

Eligibility & Authorization (VA)

Eligibility & Authorization (WA)

Eligibility & Authorization (WV)

(AZ)

(CA)

(IL)

(MI)

(NV)

(NH)

(NY)

(OH)

(OR)

(SC)

(UT)