Coordination of Benefits Between Health Plans and VSP Plans

Coordination of Benefits Between Health Plans and VSP? Plans

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ELIGIBILITY AND AUTHORIZATION

COORDINATION OF BENEFITS BETWEEN HEALTH PLANS AND VSP? PLANS

Coordination of Benefits Between Health Plans and VSP? Plans

Determining Primary Coverage

If the exam is medical, bill the health plan or Medicare as primary. If the exam is routine, bill VSP as primary unless the patient has routine coverage through their health plan.*

*Patients covered under the Federal Employees Dental and Vision Insurance Program may have routine coverage through their health plan. For more information, check the Federal Government Client Details in the Choice Network Manual.

Health Plan or Medicare as Primary Coverage

If the health plan covers the exam only, submit the exam claim to the health plan as primary and the materials claim to VSP as primary. Medical plans typically have higher copays than VSP and may have deductibles. They also don't typically pay for refraction. To save money for your patient, coordinate benefits with VSP to cover the unpaid portion of the exam, if any, including the refraction.

Submitting the Claim

z Coordinate benefits between the health plan and VSP for the exam/refraction. Tell your patient that coordinating benefits will exhaust their VSP exam benefit for the eligibility period, but will save them money.

z Submit the claim to the health plan carrier for the exam and refraction. Be sure to include a refractive diagnosis for the refraction and the appropriate diagnosis for the exam, based on your professional opinion.

z For us to consider payment, the CPT code(s) billed to the primary carrier must include an appropriate exam code plus a routine or refractive diagnosis code for the refraction. Indication of post-cataract with the diagnosis code of V43.1 will preempt the requirement for a routine or refractive diagnosis code for clients that offer a post-cataract material benefit to their members through VSP.

z We'll pay up to the secondary exam allowance, but not more than the patient's out-of-pocket expense.

For Paper Claims

z When you receive payment from the health 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.

For Electronic Claims

z When you receive payment from the health plan, keep 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/Medicare, in the patient's file.

Follow these instructions:

z Provide the same diagnosis, exam, and refraction codes from primary claim z Select Yes (box 11d) there is another health benefit plan for eyecare. This will open a new section. Be sure

to leave the field for Secondary Authorization Number blank



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z Skip the Additional Information Detail section (boxes 10, 15 ? 18, 22 & 23). This section isn't needed. z Complete the Other Insured section as below:

Enter "Same" in box 9 Enter "NA" in box 9a Enter "01/01/1901" in box 9b Enter "NA" in box 9c Enter primary health plan in box 9d

z Click "Calculate and Continue" at the top left z List amount paid by primary carrier(s) in box 29 z Enter this exact language in box 19: "secondary COB claim patient resp $XX.XX"

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



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