Participating Provider Manual - MESVision · 1994. 10. 15. · discount on non-covered benefits. MES represents participating providers with a choice of all three eye care professionals

Participating Provider Manual

Your Provider Number is ______________

Verify Eligibility or Enter Claims At: www.MESVision.com

Customer Service or Eligibility: (800) 877-6372(714) 619-4660

Please Submit Paper Claims to: P.O. Box 25209 Santa Ana, CA 92799

This manual is the sole and exclusive property of Medical Eye Services, Inc. and ECN II, Inc.,, jointly known as MESVision.

This manual contains the rules, regulations, and policies designed to assist you as a Participating Provider. The information contained in this manual is proprietary and confidential. It may not be reproduced in part or in whole, without written consent and authorization. Changes and updates to the manual are posted and/or available through the “Provider” portal of the MESVision website. If you have any questions, please contact the Provider Care Department at [email protected] or toll-free at 1 (800) 877-6372.

mailto:[email protected]

MES-CA Participating Provider Manual (08-2020) 1

Participating Provider Manual

Table of Contents Title Page Overview................................................................................................................................................ 2 Provider Responsibilities ........................................................................................................................ 3 Patient Responsibilities .......................................................................................................................... 6 Policy Statement .................................................................................................................................... 7 Department of Managed Health Care Regulatory Requirements ........................................................... 8 Assembly Bill 684 Requirements ........................................................................................................... 9 Website Eligibility Verification Guidelines ............................................................................................. 10 Interactive Voice Response System (IVR) Eligibility Verification Guidelines ......................................... 12 Website Claim Submission Guidelines ................................................................................................. 14 Claim Submission Guidelines .............................................................................................................. 15 Guidelines for Approval of Non-Elective (Medically-Necessary) Contact Lenses ................................. 16 Guidelines for Approval of Subnormal/Low Vision Testing and Low Vision Aids .................................. 16 Claim Resubmission Guidelines .......................................................................................................... 17 Reimbursement Procedures for Overpaid Claims ................................................................................ 18 Claims Processing Policies and Definitions .......................................................................................... 19 Limitations ........................................................................................................................................... 23 Exclusions ........................................................................................................................................... 24 Schedule of Allowances ........................................................................................................... Appendix I Provider Manual Amendments ................................................................................................ Appendix II Quality Management Program ............................................................................................... Appendix III Quality Improvement Policies and Procedures ...................................................................... Appendix IV Evaluation Tools .................................................................................................................... Appendix V Provider Update Form* ......................................................................................................... Appendix VI Claim Form* ......................................................................................................................... Appendix VII Non-Elective (Medically Necessary) Contact Lenses Approval Request Form*................... Appendix VIII Grievance Form* ................................................................................................................... Appendix IX Low Vision Benefit Request & Review Form* ......................................................................... Appendix X

*May be reproduced as needed.


Overview

Medical Eye Services, Inc. (MES) was incorporated in 1976 as a Preferred Provider Organization for vision plans that provide quality eye care service. MES has been licensed as a Third Party Administrator in California since 1978, holds TPA licenses throughout the United States, and is also licensed as a specialized Health Care Service Plan in California. MES has agreements with Health Maintenance Organizations, Preferred Provider Organizations, employer groups, and insurance carriers. Vision benefit designs include Full-Service Plans, Eyewear-Only Plans, Exam-Only Plans, vision plans bundled with hearing or dental, and access to a value-added discount on non-covered benefits. MES represents participating providers with a choice of all three eye care professionals. The network Ophthalmologists (MDs), Opticians, and Optometrists (ODs) accept a competitive fee-for-service schedule of allowances as payment-in-full for covered benefits. Historically, ninety-eight (98%) percent of claims are paid to participating providers with the majority of claims submitted through the MES website. Participating providers are credentialed on an ongoing basis in accordance with the standards established by the National Committee for Quality Assurance (NCQA). MES administers numerous benefit designs based on a group’s requirements or bid specifications. MES is responsible for total claims administration from eligibility verification through checkwrite including servicing all patient and provider inquiries. Random patient surveys are performed twice each month. MES continues to achieve a satisfaction level of Excellent or Good on over ninety-five (95%) percent of responses.


Provider Responsibilities For the purposes of this manual, “Patient” may also mean “Enrollee” or “Insured.” 1. To complete the appropriate portion(s) of the claim at no charge to the patient and submit the correct

copy of the claim form to MES. Although many patients may bring a claim on the date of service, they are not required to do so. You may reproduce the claim included in this manual or download it from www.MESVision.com. Providers can directly enter and submit claims on this website.

2. To collect any calendar-year deductible(s) at the time services are rendered. The calendar-year deductible is usually paid at the time of the examination. Some vision plans, however, have double deductibles (examination and eyewear). Please access www.MESVision.com for specific deductible amounts. The benefit allowance paid by MES is reduced by the deductible that is paid by the member to the provider at the time of service.

3. To inform the patient of any charges not covered under their vision plan, and/or items that have a limited benefit, and to include such documentation in the patient file (Please see Exclusions and Limitations section).

4. To arrange for payment of all non-covered items prior to rendering services. This is a private arrangement between the provider and the patient.

5. To submit “usual and customary" charges for all services and/or materials. 6. To attach documentation to the approval form and/or claim when billing for medically necessary contact

lenses, and to the claim for contact lenses and/or frame and lenses in cases of aphakia. 7. To always include the prescription on or attached to the claim, and to check the appropriate box for the

type of lenses dispensed. A prescription is required even when only the frame is being dispensed. 8. To conspicuously post in the office, a notice clearly stating the legal requirements and office policy

regarding the release of spectacle and contact lens prescriptions in accordance with applicable law. 9. To include the name, address, and provider number where indicated on the claim. It is important that

the address on the claim is the location where services are rendered. If required information is missing, a request will be generated by MES, and the claim will be pended until the information is received. If there is a problem identifying a provider, payment may be sent directly to the patient.

10. To ensure that all areas of the claim are completed before submission. This will assist in expediting claim processing and reimbursement. It is especially important that the Social Security Number or Member Identification Number is that of the covered person and not the dependent's.

11. To submit claims for processing within six (6) months from the original date of service (date of service means the calendar date on which covered services were provided). The requirements of insurance carriers, health care service plans, and employer groups indicate that claims submitted AFTER their deadline, from date of service, will be denied. Please note that patients are not responsible for claims submitted beyond the stipulated time period and therefore cannot be billed for such covered services.

12. To obtain an eligibility verification in order to verify available benefits and to establish responsibility for payment of copayments/deductibles, non-covered services, and/or materials, if any. Eligibility verifications may be obtained through the MES website (www.MESVision.com) in addition to the MES Call Center (1-800-877-6372). Eligibility verifications are subject to prescription change, IRS dependent requirements, and full-time student status, and are valid only for five (5) days before and five (5) days after date of service within the same month. Please note that an eligibility verification for self-funded ERISA groups does not guarantee payment in the event of retroactive terminations. For such situations, providers may collect from the patient or the new vision plan.

13. Payment of covered services is subject to the provisions of the patient’s vision plan.


14. To submit requests for payment adjustments timely (within 180 days) to expedite resolution and additional payment, if applicable. All disputes (including payment adjustment requests) must be submitted within 365 days of payment or denial. Please refer to the “Provider Dispute Resolution” Policy and Procedures.

15. To submit required information within deadlines, including claims submission deadline stated on pending letters.

16. To contact MES with any questions, comments, or problems regarding payments within applicable deadlines.

17. To accept reimbursement for covered services as payment-in-full and not bill the patient for any amounts that are reduced in accordance with benefit policy guidelines including, but not limited to, fee adjustments (provider's write-off) and assessments.

18. When an eligible patient does not identify her/himself as having an MES-administered vision plan, you may bill services and materials at the time of the visit. Once coverage is disclosed, the participating provider is required to refund the amount paid by the patient less any copayments/deductibles, any assessments if applicable, and payments for non-covered services or materials. Any patient responsibility will be shown on the Explanation of Payment. The patient must disclose coverage to the provider within the 180-day grievance filing deadline. In the event your posted office policy states that coverage must be disclosed at the time of service, obtaining the patient’s written acknowledgement of this policy and all office policies is recommended.

19. To advise MES of any change in information, including change in ownership of the practice, address, telephone number, tax information, and/or opening of additional locations.

20. To advise MES of new licensed associates who have joined the practice. MES requires all licensed providers in the same office who perform routine examinations to participate in the network.

21. To enroll the licensed optical dispensary as a participating provider, if lenses and frames are dispensed. 22. To have a selection of at least 50 frame styles that are covered-in-full, if lenses and frames are

dispensed. 23. To only bill for the actual out-of-pocket expenses incurred by the patient when there is Coordination of

Benefits with another vision plan. Copies of the benefit form and the Explanation of Payment from the primary vision plan are required.

24. To ensure that all advertising regarding provider participation is not untrue, misleading, deceptive or otherwise inconsistent with existing law.

25. To advise patients who purchase disposable contact lenses that these items are covered up to their plan’s benefit allowance. Patients should be allowed to purchase lenses up to their plan’s benefit allowance or accumulate receipts within their benefit period, and then submit a claim for reimbursement. Benefit periods may be twelve (12) months or twenty-four (24) months, depending on the plan design.

26. To remind patients, when applicable, that it is their responsibility to pay the difference between the comprehensive examination allowance and the follow-up examination allowance when they elect to receive a comprehensive examination but are only eligible for a follow-up examination. Any charge that exceeds the comprehensive examination allowance is a provider write-off.

27. To communicate freely with patients about their treatment, regardless of benefit coverage limitations. 28. To refer patients covered under HMOs back to their Primary Care Physician or Participating Medical

Group when it is suspected that additional diagnostic procedures or treatment plans may be required. Participating provider must cooperate with ultimate treating physician and provide any documentation to assure continuity of care.

29. To advise MES of any change license status or any actions brought by any professional organization and/or state agency against your license and/or practice.


30. To notify patients of changes in the status of your MES network participation (e.g. resignation, termination, etc.) prior to rendering services. This will allow patients to seek services from MES participating providers, if they wish to.

31. To conduct your practice within accepted norms and standards of the community. 32. To abide by the bylaws, participating provider agreement, rules, regulations, and policies and

procedures adopted by the Board of Directors. 33. To obtain MES’ and carrier partners’ written consent prior to use of the name, trademark(s), service

mark(s) of Medical Eye Services, Inc. (MES), ECN II, Inc. (ECN II), MESVision, or any of its carrier partners including Blue Shield of California.

34. To notify MES promptly and not exceeding five (5) business days of any provider directory information changes, including whether provider is accepting or not new patients.

35. To direct enrollee or potential enrollee to both the plan for additional assistance and to the Department of Managed Healthcare to report any inaccuracy with the MES’ participating provider directory, if a provider who is not accepting new patients is contacted by an enrollee or potential enrollee seeking to become a new patient.

None of the provider’s responsibilities listed above shall interfere with the provider’s ability to provide information or assistance to their patient.


Patient Responsibilities

1. To inform the provider of their vision coverage, preferably on or before the date of service. Although many patients may bring a claim on the date of service, they are not required to do so. If the patient does not present the claim at the time of service, please call to verify eligibility and use a duplicate of the claim that is provided with this manual or downloaded from the MES website (www.MESVision.com). It is imperative that you secure an eligibility verification number in order to use this form. When an eligible patient does not identify her/himself as having an MES-administered vision plan and pays for services and materials at the time of visit, any submitted claim will be paid directly to the participating provider. The participating provider is required to refund the amount paid by the patient less any copayments/deductibles, plus any write-offs or applicable assessments, and payments for non-covered services or materials.

2. To complete all information in Part 1 of the claim, and to release the signed and dated form. 3. To pay any copayments/deductibles for each patient at the time services are rendered. 4. To pay the difference between the comprehensive examination allowance and the follow-up

examination allowance when they elect to receive a comprehensive examination but are only eligible for a follow-up examination.

5. To arrange for payment of any services/materials listed under the Exclusions and Limitations of the vision plan (please see Exclusions and Limitations section).


Policy Statement

Subject: Provision of Contact Lens Specifications (Adopted by the Board of Directors at its meeting held October 15, 1994) Background The fitting of contact lenses and the written specifications of such contact lenses differ from the determination of the power and characteristics of eyeglasses. With glasses, it is usually possible to arrive at a scientifically valid determination of the optical power of the spectacles at the completion of the initial examination. Therefore, a “prescription” for glasses can be written, for which the provider is commonly considered to be responsible. However, in the case of contact lenses, the performance of the lenses on the eyes must be evaluated before the fitter can determine the final specifications. Evaluation The initial comprehensive examination cannot determine all the parameters needed for properly-fitted contact lenses. The initial examination includes a comprehensive ophthalmic evaluation to diagnose the presence or absence of eye disease, and a refraction to determine any optical correction that may be needed. Based on these and other measurements, the physical and optical specifications of trial contact lenses can be approximated. The evaluation of the fit of the lenses is equally important. During the fitting process, trial contact lenses are applied to the patient’s corneas. In some instances, a satisfactory fit is obtained, while in others, lenses of difference sizes and curvatures must be used. Sometimes it is necessary to utilize several trial lenses before obtaining an adequate physical fit of both eyes. An over-refraction is then performed to determine the exact optical power of the lenses. Following delivery of these lenses, the patient is carefully re-evaluated. In some cases, after a period of wear, these lenses may no longer be satisfactory, and lenses with other specifications may be necessary in one or both eyes. Summary The fitting of contact lenses involves more than the issuance of a “prescription”. The continuous evaluation of the fitting characteristics of the lenses is equally important.


Department of Managed Health Care Regulatory Requirements The following provisions are required by Title 28 of the California Code of Regulations, Section 1300.67.8 for all contractors that provide services to Health Care Service Plans. 1. The participating provider agrees to maintain such records and provide such information to the plan or

to the Commissioner of the Department of Managed Health Care as may be necessary for compliance by the plan with the provisions of the Knox-Keene Health Care Service Plan Act of 1975, as amended. Such records will be retained for at least two years whether or not this agreement is terminated by rescission or otherwise.

2. The plan shall have access at reasonable times upon demand to the books, records, and papers relating to the health care services provided to enrollees, to the cost thereof, and to payments received from enrollees of the plan (or from others on their behalf).

3. Upon termination of this agreement, the participating provider agrees to continue providing services to the enrollees under his or her care at the then current rates until the services being rendered are completed, unless the plan makes reasonable and medically appropriate provision for the assumption of such services.

4. The participating provider agrees to bill the plan directly for covered services rendered to eligible enrollees rather than seeking reimbursement from the enrollees except for applicable copayments/deductibles.

5. If the plan fails to pay for covered services or supplies, the participating provider will not collect or attempt to collect from an enrollee sums owed by the plan. The enrollee shall not be liable to the participating provider in the event the plan fails to pay for services or supplies covered by the enrollee's contract with the plan.

6. The participating provider shall comply with the plan’s Timely Access to Non-Emergency Health Care Services policies and procedures it has developed pursuant to Section 1367.03 of the Knox-Keene Act and Title 28, California Code of Regulations, Section 1300.67.2.2 (a)(2), that are applicable to specialized plans.

7. The participating providers shall comply with the plan’s Language Assistance Program (LAP) developed pursuant to section 1367.04 of the Knox-Keene Act and Title 28, California Code of Regulations, Section 1300.67.04 (e)(4).

8. The participating providers shall comply with the plan’s provider directory standards developed pursuant

to section 1367.27 of the Knox-Keene Act that are applicable to specialized plans.


Assembly Bill 684 Requirements California Assembly Bill 684 requires the following provisions for all optometrists, as applicable. Participating provider hereby attests that:

1. Provider shall comply with all applicable professional practice laws and shall provide MES with any

documents that MES may request regarding such compliance. 2. Provider shall report to MES any investigation, action or request for information received by provider

from the Board of Optometry, the Medical Board of California, or any other regulatory entity. 3. If provider is an optometrist subject to Business and Professions Code Section 655(d), Provider agrees

to amend the sublease into which provider has entered to comply with the requirements of Assembly Bill 684 (effective January 1, 2016).

4. To the best of Provider’s knowledge, Provider will comply with the laws contained in Assembly Bill 684 (effective January 1, 2016), to the extent that such laws apply to Provider.

5. Provider will inform the MES if it is subleasing space from a health plan, optical company, and/or registered dispensing optician, as applicable.


Website Eligibility Verification Guidelines www.MESVision.com

This section details the process of verifying eligibility and confirming the eligible benefits of a plan participant/patient. If at any time you need assistance, please contact a Call Center Representative during normal business hours, 8:00 am – 5:00 pm PST, Monday through Friday. Please note a claim can only be filed online with an eligibility verification number. How to Access the Website

Log on to www.MESVision.com.

1. Select the “Log In” entry button on top of the MES home page. From the drop-down list, select the “Provider Login” button.

2. Enter your User Name (Provider Number) and Password (use the same numbers as you would to access telephonic eligibility).

Note: The system only accepts five-digit user numbers. If your provider number is less than five digits, please place zeros in front of your number. (Example: provider number “456” would be entered as provider number 00456.)

3. Once the system confirms your network participation, you are then directed to the Care Provider

Home Page. To Obtain a Verification

1. Select “Verify Your Patient’s Eligibility” button on the Care Provider home page. This will take you to the Subscriber Search page.

2. Search by ID Number: Enter the patient’s social security number or unique identification number; or

3. Search by Subscriber Name: Enter the subscriber’s first and last names, and birth date. All three data elements are needed to execute this search.

Note: If the search is unsuccessful, a box with “Subscriber not Found” will appear at the top of the Subscriber Search Page. Please double-check the entered data and try again.

4. Subscriber Search Results: Includes subscriber name, group name, group number, and birth date.

You are also given the option to conduct another search should this individual not be the patient for whom you are verifying eligibility. If the patient listed is correct, select the patient’s name to reveal the status of covered dependents.

5. Subscriber and Dependents Page: Includes a list of covered dependents for a specific subscriber.

Once you have located the appropriate patient, select the name and you will be routed to the Subscriber Benefits page.

6. Subscriber Benefits Page: Available benefits are presented including covered services (exam,

lenses, and frame), benefit copayments/deductibles, and eligibility dates. 7. Select the types of services that will be performed during the visit.

http://www.mesvision.com/


Note: Be sure to mark only those services you are able to perform during the visit; marking eyewear when you only perform exams will prevent another participating provider from securing an eyewear eligibility verification.

8. Enter the appropriate date of services then select “Get Verification Number”. 9. The eligibility verification number for your patient will be displayed. We encourage you to print this

page for your patient’s file.

After you receive the eligibility verification number and print a copy of the page, you may: • Return to the Care Provider Home Page to verify eligibility for another patient; • Select “Enter Claims” at the top of the page to proceed to the claims submission portal; or • End your user session by logging off.

To view enhancements made to the process throughout the year, please visit our website, www.MESVision.com.


Interactive Voice Response System (IVR) Eligibility Verification Guidelines

After hearing the initial greeting and menu of options, you will be able to utilize the voice recognition feature or continue to use your telephone’s key pad to change your access code, generate or cancel an Eligibility Verification for your patient(s). You can interrupt the instructions – Quick Pace – at any time by entering your request. This will allow you to move through the process at a much quicker pace once you are familiar with the system. How to Access the IVR

Call (800) 877-6372 or (714) 619-4660. You will hear the initial greeting and menu of options:

1. If you are calling from a provider’s office, press “1” 2. For Eligibility Verification, press “1”

At any time, you can press “*” to speak to a representative during normal business hours.

3. Please enter your provider number 4. Please enter your access code

To Obtain a Verification

1. Please press “1” 2. Please press “1” if using a nine (9) digit SSN; or 3. Please press “2” if using an identification number 4. Please press “1” if services will be rendered today; or 5. Please press “2” if services will be rendered on a different date

i. Please enter the six (6) digit date of service in the following format: mm/dd/yy 6. Please press “1” if the patient is the Primary Subscriber; or 7. Please press “2” if the patient is a Spouse or Domestic Partner; or 8. Please press “3” if the patient is a Dependent

i. If the patient is a dependent, you will then be asked to enter the dependent’s eight (8) digit date of birth in the following format: mm/dd/yyyy

The system will list all available services for the patient, including any allowances for custom benefits.

The system will say the patient’s deductible or co-payment, if applicable. If there is no deductible or co-payment the system will be silent.

9. Please press “1” if you are dispensing standard lenses 10. Please press “2” if you are not dispensing standard lenses

i. If “No” was selected, the system will list the applicable lens options and benefit amounts 11. Please press “1” to receive your verification number 12. Please press “2” for other options

Generate Additional Verifications

1. Please press “1” if the patient is under the same subscriber 2. Please press “2” if the patient is under a new subscriber 3. Please press “3” to cancel a verification 4. Please press “4” if you would like to change to a different provider number 5. Please press “5” to go back to the main menu 6. Please press “6” if you would like to have these options repeated


To Change your Access Code

1. Please press “2” from the main IVR menu 2. Please enter your new access code. The new access code must be between 4 to 8 digits in length 3. To confirm your access code, please enter your new access code number

Please record your new access code as it will be required for future transactions.

To Cancel an Eligibility Verification

1. Please press “3” from the main IVR menu 2. Please press “1” if the name is correct 3. Please press “3” if you would like the name spelled to further confirm the patient’s name 4. Please press “2” if it is not the correct patient 5. Please press “1” if the patient rescheduled the appointment 6. Please press “2” if the patient cancelled the appointment 7. Please press “3” if the patient never showed up for the appointment 8. Please press “9” for other reasons 9. To cancel an additional eligibility verification, please press “1” 10. To change to a different provider number, please press “2” 11. To return to the main menu, please press “3”

Please remember, you can press “*” at any time during this process to speak to a Call Center Representative during normal business hours, 8:00 am – 5:00 pm PST Monday through Friday.


Website Claim Submission Guidelines www.MESVision.com

This section details the process of submitting a claim for services rendered to an eligible patient. Please note a claim can only be filed online with an eligibility verification number. How to Access the Website

Log on to www.MESVision.com.

1. Select the “Care Provider” entry button on the MES home page. 2. Enter your User Name (Provider Number) and Password (use the same numbers as you would to

access telephonic eligibility).

Note: The system only accepts five-digit user numbers. If your provider number is less than five digits, please place zeros in front of your number. (Example: provider number “456” would be entered as provider number 00456.)

3. Once the system confirms your network participation, you are then directed to the Care Provider

Home Page. To Submit a Claim

1. Select the “Enter A Claim” button on the Care Provider Home Page. 2. The “Enter Claims” page will list all outstanding verification numbers, subscriber and patient names

for your provider number. 3. Select the Subscriber name with the appropriate patient name to begin the claim submission

process. This will take you to the Patient Confirmation page. 4. The “Patient Confirmation page” provides you with a summary of eligible and ineligible benefits

along with copayments/deductible information for the selected patient. 5. Once you have verified the correct patient, select “Continue” to proceed to the “Enter A Claim” page. 6. On the “Enter A Claim” page, complete all claim information regarding the services you rendered.

To facilitate data entry, some fields are pre-filled with data from the eligibility verification process.

Please note: The system will only proceed after all required information is entered.

7. Check the box indicating you have read and understood the fraudulent claim statement. 8. Select the “Submit Claim” button to proceed. 9. Congratulations! The “Claim Confirmation Page” is presented when a claim is correctly submitted

for processing. This screen lists the MES claim number and all data provided for the claim. We encourage you to print a copy of this screen for your file.

Once you complete this process and print a copy of this page, you may:

• Submit additional claims, • Return to the Care Provider Home page; or • End your user session by logging off.

To view enhancements made to the process throughout the year, please visit our website, www.MESVision.com or to speak to one of our specially trained web experts, call us at: 1-800-877-6372, Option “4”

http://www.mesvision.com/


Claim Submission Guidelines

The claim is easy to complete and is accepted by every insurance carrier that underwrites vision plans administered by MES. MES implemented a claims-imaging system that eliminates many of the manual steps, from claims receipt to checkwrite, thus expediting the claims processing. To maximize this system’s benefits, it is important that claims are not highlighted, and free of erasures. It is to your advantage to ensure that each section is properly completed. Part 1 (To Be Completed By the Patient)

1. Employee's Name and Home Address 2. Employee Social Security Number or Identification Number 3. Patient's Name 4. Patient's Date of Birth 5. Name of Employer 6. Policy Number (from Human Resources or Benefits Officer) 7. Full-time Student Status (if applicable)

Part 2 (To Be Completed By the Examining Doctor)

1. Date of Examination 2. CPT or HCPCS Code and Examination Fee 3. Complete Prescription (if applicable) 4. Lens Type (if applicable) 5. Provider's Name, Address, and Provider Number 6. Eligibility Verification Number

Part 3 (To Be Completed By the Dispenser)

1. Date of Order and Date of Delivery of Eyewear 2. Itemization of All Charges 3. Lens Type (if applicable) 4. Contact Lens Manufacturer and Brand (if applicable) 5. Provider's Name, Address, and Provider Number 6. Eligibility Verification Number

When a patient is covered under two plans administered through MES, two claims are required. Each claim must contain the appropriate employee social security number or identification number. If there is a copayment/deductible under the primary coverage, copayment/deductible is waived when overages are billed under the secondary coverage. A master copy of the claim is included with this manual and may be duplicated as required, or downloaded from www.MESVision.com. Claims may also be directly entered and submitted through this website. Completed claims must be mailed to P. O. Box 25209, Santa Ana, CA 92799 or entered through the website at www.MESVision.com. To confirm receipt of submitted claims, please call the MES Customer Service Department at 1-800-877-6372.


Guidelines for Approval of Non-Elective (Medically-Necessary) Contact Lenses

Providers should submit a written request for approval of medically-necessary contact lenses or they may call the Customer Service Department to initiate a request by plan. The provider must clearly indicate which condition(s) are met. The process requires the following information:

1. An explanation of the patient’s condition 2. Best corrected visual acuity with glasses 3. Best corrected visual acuity with contact lenses, if available 4. Contact lens specifications 5. Spectacle prescription 6. Topography, corneal thickness readings, or k-readings should be submitted to support the diagnosis

of Keratoconus 7. Doctor’s signature 8. The patient’s history and the claim, when applicable.

Please refer to Quality Improvement Policy and Procedure (QIP&P) #17, “Non-Elective (Medically Necessary) Contact Lenses Procedure” contained in this Participating Provider Manual for more information. To view enhancements made to the process throughout the year, please visit our website, www.MESVision.com.

Guidelines for Approval of Subnormal/Low Vision Testing and Low Vision

Aids Following the completion of a comprehensive eye examination, when the need for low vision aids is indicated, providers should submit the appropriate request form for approval of subnormal/low vision testing and low vision aids or they may call the Customer Service Department to initiate a request. The provider must clearly indicate appropriate diagnoses which meet established criteria. The patient record and any supporting documents must demonstrate functional and/or quality of life improvement. Please refer to Quality Improvement Policy & Procedure (QIP&P) #18, “Low Vision” contained in this Participating Provider Manual for more information.


Claim Resubmission Guidelines

There are some circumstances that require claims to be resubmitted and reprocessed. The maintenance of audit controls demands that specific documents be submitted in order to correct information on a claim that has been paid, denied, or is in process. If a request is submitted without the necessary documentation, you will receive a letter requesting specific documents. It is necessary to submit a copy of the patient’s records, signed by the provider, that contain the following: To change the date of service

1. the date of service 2. the services rendered 3. provider notes regarding the requested change

To change the eyewear prescription

1. the date of service 2. the services rendered 3. the prescription 4. provider notes regarding the requested change 5. copy of optical lab bill

To change the type of lens or eyewear

1. the date of service 2. the services rendered 3. the prescription 4. provider notes regarding the requested change 5. a copy of the optical lab bill

Please note that final disposition of the claim is subject to review of the requested information.


Reimbursement Procedures for Overpaid Claims

1. As soon as a claim overpayment is determined, MES shall submit a written request for reimbursement to the participating provider within 365 days following the original date of payment.

2. The request shall identify the patient name, subscriber’s identification number/social security number, claim number, date of service, and a clear explanation of why the payment is in excess of the amount due.

3. Participating providers must submit the requested claims overpayment to MES within thirty (30) working days of receipt.

4. If it is necessary to contest the reimbursement request, the provider shall submit a written notice to MES within thirty (30) days of receipt.

5. The provider’s written notice shall include the basis on which the provider believes the claim is not overpaid. The dispute resolution procedures for participating providers shall be followed.

6. MES may offset an uncontested request for reimbursement against a participating provider’s current claim submissions if the provider does not submit payment within thirty (30) working days of receipt. This adjustment shall be reflected on the Explanation of Benefits and shall identify the claim number, patient name, subscriber identification number/social security number, date of service, and payment adjustment amount.


Claims Processing Policies and Definitions Prescription Change In order for new lenses to be paid at a twelve-month interval, any one of the following criteria must be met: 1. A change of 0.50 diopter or more in one eye, or total in both eyes. 2. A shift in the axis of the cylinder of 15 degrees, or less than 15 degrees on a graduated scale as the

cylinder power increases over .75 diopter. The graduated scale is based on the shift in the axis multiplied by the cylinder power resulting in a factor of 8 or more (see Table below).

Degrees Of Axis Change

Cylinder Power

O.25 0.50 0.75 1.00 1.25 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00 5.50 6.00 6.50 7.00 7.50 8.00

Factors

1 0.25 0.5 0.75 0.25 1.25 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8

2 0.5 1 1.5 2 2.5 3 4 5 6 7 8 9 10 11 12 13 14 15 16

3 0.75 1.5 2.25 3 3.75 4.5 6 7.5 9 10.5 12 13.5 15 16.5 18 19.5 21 22.5 24

4 1 2 3 4 5 6 8 10 12 14 16 18 20 22 24 26 28 30 32

5 1.25 2.5 3.75 5 6.25 7.5 10 12.5 15 17.5 20 22.5 25 27.5 30 32.5 35 37.5 40

6 1.5 3 4.5 6 7.5 9 12 15 18 21 24 27 30 33 36 39 42 45 48

7 1.75 3.5 5.25 7 8.75 10.5 14 17.5 21 24.5 28 31.5 35 38.5 42 45.5 49 52.5 56

8 2 4 6 8 10 12 16 20 24 28 32 36 40 44 48 52 56 60 64

9 2.25 4.5 6.75 9 11.25 13.5 18 22.5 27 31.5 36 40.5 45 49.5 54 58.5 63 67.5 72

10 2.5 5 7.5 10 12.5 15 20 25 30 35 40 45 50 55 60 65 70 75 80

11 2.75 5.5 8.25 11 13.75 16.5 22 27.5 33 38.5 44 49.5 55 60.5 66 71.5 77 82.5 88

12 3 6 9 12 15 18 24 30 36 42 48 54 60 66 72 78 84 90 96

13 3.25 6.5 9.75 13 16.25 19.5 26 32.5 39 45.5 52 58.5 65 71.5 78 84.5 91 97.5 104

14 3.5 7 10.5 14 17.5 21 28 35 42 49 56 63 70 77 84 91 98 105 112

15 * 3.75 * 7.5 11.25 15 18.75 22.5 30 37.5 45 52.5 60 67.5 75 82.5 90 97.5 105 112.5 120 * Acceptable with 15 degrees of change. 3. A difference in prism correction greater than 1 Δ prism diopter. 4. A change from glasses to contact lenses or contact lenses to glasses (Please see Exclusions and

Limitations section). 5. A change in lens type (i.e., single vision to bifocals, bifocals to single vision, etc.), but retaining the same

prescription (Please see Exclusions and Limitations section).


Non-Elective (Medically- Necessary) Contact Lenses Payment is considered as payment-in-full when contact lenses are provided for any of the conditions listed below: 1. Aphakia (after cataract surgery); A pair of single vision lenses or multi-focal lenses and frame may be

provided with the contact lenses. 2. Keratoconus, i.e., when visual acuity cannot be corrected to 20/40 with the use of spectacles, or if other

conditions indicate (please include K readings or topography for approval); 3. Anisometropia of 3.0 diopters or more, provided visual acuity improves to 20/60 or better in the weaker

eye; 4. Myopia of 12 diopters spherical equivalent or greater; 5. Hyperopia of 7 diopters spherical equivalent or greater; 6. Astigmatism of greater than 3.0 diopters of cylinder; or 7. Other (i.e. various corneal findings and disorders) Note: The narrowing of visual fields due to high minus or plus corrections is NOT considered a reason for non-elective (medically necessary) contact lenses. The guidelines (criterion) above are used to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under the enrollee’s contract. Subnormal/Low Vision Testing and Low Vision Aids Criteria for Low Vision (best corrected visual acuity (BCVA) in the better eye): 1. Moderate: BCVA is 20/70 or less 2. Severe: BCVA is 20/200 or less (legal blindness), or visual field is 20 degrees or less 3. Profound: BCVA is 20/400 to 20/1000, or visual field is 10 degrees or less 4. Hemianopsia (with or without macular sparing)

Note: The patient history and/or supporting documentation must demonstrate functional and/or quality of life improvement. Standard Lenses Plastic lenses and, if covered by the patient’s benefit plan, glass lenses with an eye size of less than 61 mm based on the patient’s benefit plan. Standard Bifocal Lenses RD 22mm or 24 mm FT 25mm or 28 mm Standard Trifocal Lenses 7x25mm or 7x28mm Oversize Lenses Standard lenses fit any “frame with an eye size less than 61mm". Lenses with an eye size of 61mm or greater are considered oversize lenses.


Contact Lenses for Cosmetic or Convenience Purposes Contact lenses for cosmetic/convenience purposes are reimbursed based on the schedule of allowances. Any balance is the patient’s responsibility. To determine the appropriate benefit allowance, all contact lens claims must include the contact lens manufacturer and brand. Prevailing Fees Fees that are in the range of the usual and customary fees charged by the providers of similar training and experience for identical services within the same geographical area. Limited or Non-Covered Materials Participating providers can charge a "reasonable retail amount" for non-covered materials and services listed under the Exclusions and Limitations section, once the patient is informed of and agrees to these charges. Comprehensive Examination A comprehensive examination (including but not limited to 92004, 92014, and 92015) is a level of service in which a general evaluation of the complete visual system is made. It constitutes a single service entity but need not be performed at one session. The service includes case history, visual acuity, objective and subjective refraction, external examination, neurological integrity, binocular status, tonometry, peripheral visual fields screening, biomicroscopy, and funduscopic examination. It may or may not include cycloplegia or mydriasis. It may include diagnostic and treatment programs as indicated. Determination of the refractive state is the quantitative procedure that yields the refractive data necessary to determine the best visual acuity with lenses and to prescribe lenses. It is not a separate medical procedure, or service entity, but is an integral part of the general eye care services, carried out with reference to other diagnostic procedures. The evaluation of the need for and the prescription of lenses are never based on the refractive state alone. Determination of the refractive state is not reported separately. The refraction is part of the comprehensive eye care services, and the intermediate (follow-up) services to an established patient who, under continuing active treatment with periodic observation, may not require comprehensive re-evaluation. Note: In the event that the provider determines that additional diagnostic procedures or treatment plans are indicated, the patient will need to obtain care under her/his medical plan. Patients who are covered under HMOs must be referred back to their Primary Care Physician or Participating Medical Group. Intermediate Examination An intermediate (follow-up) examination (including but not limited to 92002, 92012, and 92015) is a level of service provided to an existing patient to determine the refractive state. It should include the evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated or deemed necessary. Note: Intermediate (follow-up) examinations are paid at a reduced level (please refer to the Schedule of Allowances example). Any difference in charges that exceed the follow-up examination allowance is a provider write-off. In order to receive the maximum benefit and to optimize continuity of care, the patient should see the same doctor for both the comprehensive and follow-up examinations. When the patient selects a different provider to perform the follow-up examination, the patient will be responsible for the difference between the follow-up benefit allowance and the comprehensive benefit allowance. A patient


who is only eligible for an intermediate (follow-up) examination and who elects to receive a comprehensive examination may be billed the difference between the comprehensive examination allowance and the follow-up examination allowance. It is the provider’s responsibility to advise the patient of this additional expense. Any charge, however, that exceeds the comprehensive examination allowance is a provider write-off. In the event that the provider determines that additional diagnostic procedures or treatment plans are indicated, the patient will need to obtain care under her/his medical plan. Patients who are covered under HMOs must be referred back to their Primary Care Physician or Participating Medical Group. Second-Opinion Examination A patient may request from MES a second-opinion examination. A request for second opinion will be acknowledged within five (5) calendar days of receipt of the request. A determination letter will be sent within thirty (30) calendar days of the request. If approved, the enrollee will be informed to present the approval letter to the participating provider of their choice. Please call for an eligibility verification number when presented with the notification of approval for a second-opinion examination. The participating provider performing the second opinion examination shall immediately furnish his/her findings to MES. The participating provider shall not collect a copayment/deductible from the patient. Upon receipt and processing of the claim, MES will pay the participating provider the comprehensive examination benefit.


Limitations (Limitations are paid up to the applicable Schedule of Allowances. The patient is responsible for the

amount of the provider’s charge exceeding the benefit allowance.) 1. Premium Progressive Lenses 2. Flat-Top 35 3. Executive-Style Bifocals/Trifocals 4. Oversize Lenses 5. Beveled or Faceted Lenses 6. Coated Lenses 7. Non-standard frame 8. Contact Lenses (cosmetic/convenience) 9. Rigid gas permeable scleral and hybrid contact lenses may be partially covered for patients who meet

the Non-Elective Contact Lens Criteria and when other contact lens approaches have been demonstrated to be unsuccessful. Ocular surface diseases and treatment of underlying ocular pathologies are generally covered under the patient’s medical plan.

10. When “one pair” or “100%” is specified in the patient material for medically-necessary contact lenses: If the patient meets the medically necessary criteria through the pre-approval process and the patient opts for daily disposable lenses, multi-focal lenses, or other specialty contact lenses, the patient will be responsible for 80% of the balance of the provider’s charge exceeding the benefit allowance of $350.00.

11. Hi-index/Polycarbonate Lenses 12. Photochromic (glass or plastic) Lenses 13. Polarized Lenses 14. Glass Lenses, based on the patient’s benefit plan 15. Non-prescription (plano) eyewear, when specifically covered 16. Subnormal/low vision testing and low vision aids, when specifically covered 17. Some designer frames may be restricted by the manufacturer 18. Any promotions and/or discounts that are combined with covered services under the Policy


Exclusions 1. Orthoptics 2. Vision training 3. Lenses or frames furnished under the vision plan that have been lost, stolen, or broken, except when

benefits are otherwise available 4. Tints*, other than those included in the Schedule of Allowances 5. Frame case 6. Contact lens fitting fees, except when benefits are otherwise available 7. Contact lens insurance, care kits, and supplies 8. Eyewear when there is no prescription change, except when benefits are otherwise available 9. Benefits for changes in eyewear or lens type (i.e. glasses to contact lenses and vice-versa, single vision

to bifocals, bifocals to single vision, etc.) but retaining the same prescription, except when allowed by contractual agreements

10. Medical or surgical treatment of the eyes, including treatment of any suspected pathology or injury that may be uncovered during the course of a covered vision examination and that may be payable under the medical benefits of the Enrollee’s health plan. In the event that the provider determines that additional diagnostic procedures or treatment plans are indicated to confirm the suspected pathology or injury, the Insured will need to obtain care under her/his medical plan. Enrollees who are covered under their medical plan should be referred back to their primary care physician or participating medical group

11. Eye examinations required by an employer as a condition of employment 12. Any service or material provided by another vision plan, except benefits payable under Coordination of

Benefits 13. Conditions covered by Workers' Compensation 14. Charges for which the patient is not required to pay. 15. Any charges billed by the provider for placing new lenses in the Enrollee’s own frame.

*Some contracts may provide coverage for other tints. This information may be pre-imprinted in the Comments Section, Part 3 of the claim.

Appendix I

Appendix I Schedule of Allowances (08-2020) 1

The following Medical Eye Services (MES) California schedule reflects the minimum and maximum compensation to participating providers. This schedule is applicable to patients with vision plans underwritten by MES under the California Department of Managed Health Care. Patient-specific levels of reimbursements are available via eligibility verification through the website, IVR, and Call Center.

MES-California Schedule of Allowances

The network of Opticians, Optometrists (ODs), and Ophthalmologists (MD) accept a competitive fee-for-service schedule of allowances as payment-in-full for covered benefits. When covered services and/or materials are provided by a participating provider, payments will be within the “High” and “Low” allowances listed below. Participating Provider allowances shall be accepted as payment-in-full unless otherwise specified in the footnotes. Copayment/Deductible Amounts: The copayment/deductible is an amount of charges for eligible vision expenses you incur for which no benefits will be paid. The copayment/deductible amount will apply to services and/or materials in any 12 or 24-month benefit period for each patient. Exam .....................................................................................................................................................$0.00 – $50.00 Eyewear ................................................................................................................................................$0.00 – $50.00 Retinal Imaging .....................................................................................................................................$0.00 – $50.00 Benefits Range of Allowances Low High Comprehensive Examination ..................................................................................................... $35.00 $70.00 Intermediate (Follow-up) Examination ....................................................................................... $32.50 $38.80 Examination without Dilation ...................................................................................................... $35.00 $60.00 Retinal Imaging ........................................................................................................................... $10.00 $75.00 Contact Lens Fitting & Evaluation (1)

Standard ............................................................................................................................... $20.00 $60.00 Complex ............................................................................................................................... $20.00 $240.00

Lenses (per pair): Lenses up to 61mm ................................................................................................................................. Included Single Vision ........................................................................................................................ $30.00 $52.00 Bifocals ................................................................................................................................. $45.00 $72.50 Trifocals ............................................................................................................................... $50.00 $89.50 Standard Progressive (2) ....................................................................................................... $50.00 $100.00 Premium Progressive (3) ....................................................................................................... $50.00 $300.00 Aphakic/Lenticular Monofocal .............................................................................................. $80.00 $125.00 Aphakic/Lenticular Multifocal................................................................................................ $80.00 $200.00 7.25 diopters or more high-powered lenses (per lens) (4) .................................................. +$10.00 +$16.00 Prism - 1 ½ to 4 diopters (per lens) (4) .................................................................................. +$5.00 +$15.00 Prism - 4 ½ to 10 diopters (per lens) (4) .............................................................................. +$10.00 +$20.00 Slab-Off Prism (per lens) (4) ................................................................................................ +$30.00 +$90.00 Polycarbonate for covered children up to age 19-28

Single ............................................................................................................................. $45.00 $95.00 Bifocal ............................................................................................................................ $65.00 $115.00 Trifocal ........................................................................................................................... $65.00 $130.00 Progressive .................................................................................................................... $65.00 $160.00 Premium Progressive (3) ................................................................................................ $65.00 $360.00

Plastic Photochromic: Single ............................................................................................................................. $75.00 $155.00 Bifocal .......................................................................................................................... $110.00 $175.00 Trifocal ......................................................................................................................... $115.00 $190.00 Progressive .................................................................................................................... $80.00 $220.00 Premium Progressive (3) ................................................................................................ $80.00 $420.00

Appendix I


Plastic Photochromic/Polycarbonate Single ........................................................................................................................... $100.00 $200.00 Bifocal .......................................................................................................................... $120.00 $220.00 Trifocal ......................................................................................................................... $130.00 $230.00 Progressive .................................................................................................................... $95.00 $280.00 Premium Progressive (3) ................................................................................................ $95.00 $440.00

Tint (4), (5) Single ............................................................................................................................. +$8.00 +$20.00 Bifocal ......................................................................................................................... +$13.00 +$30.00 Trifocal ......................................................................................................................... +$17.00 +$40.00 Pink or Rose Tint #1 or #2 ................................................................................................................ Included Gradient ........................................................................................................................... $5.00 $20.00

Coatings (4) Scratch ............................................................................................................................. $2.50 $10.00 Ultraviolet/UV ................................................................................................................... $2.50 $10.00 Mirrored ......................................................................................................................... $20.00 $60.00 Anti-reflective

Basic........................................................................................................................ $20.00 $60.00 Premium .................................................................................................................. $40.00 $120.00 Ultra ......................................................................................................................... $60.00 $180.00

Edging / Polishing .................................................................................................................. $2.50 $10.00 Contact Lenses: (6)

Non-Elective/Medically-Necessary (one pair) (7) ............................................................... $225.00 $350.00 Elective/Cosmetic without UV Protection ............................................................................. $75.00 $500.00 Elective/Cosmetic with UV Protection ................................................................................ $100.00 $550.00

Frame: (8) .................................................................................................................................... $30.00 $400.00 VDT (Video Display Terminal Benefit)

Lenses: Single ............................................................................................................................. $30.00 $52.00 Bifocal ............................................................................................................................ $45.00 $72.50 Trifocal ........................................................................................................................... $50.00 $89.50 Standard Progressive (2) ................................................................................................ $50.00 $100.00 Premium Progressive (3) ................................................................................................ $50.00 $300.00

Frame: (8) .............................................................................................................................. $30.00 $500.00 Plano Sunglasses (In lieu of prescription lenses and frames and/or contact lenses) (9) ............ $30.00 $400.00 Low Vision Evaluation/Follow-Up/Training and Low Vision Aid (10) .....................................................up to $1,000.00 (1) A standard contact lens fitting is for existing contact lens users who wear disposable, daily wear, or extended

wear contact lenses. It includes two follow-up visits within three months. The standard contact lens fitting is covered in full following any applicable copayments or deductibles. A complex contact lens fitting is for a patient who has never worn contact lenses or who requires a more complex fitting for toric, gas permeable, or multi-focal contact lenses. Both standard and complex fittings may include two fitting/evaluation follow-ups within three months. Any amount over the allowance is patient’s responsibility.

(2) Standard progressive lenses (also referred to as no-line bifocals) allow the patient to see distance, mid-range

and near clearly; however, there may be some peripheral distortion. Standard progressive lenses also need to be a minimum height in order to transition properly between distance and near vision. Standard progressive lenses are a covered-in-full benefit; any balance exceeding the provider’s usual and customary charge is a provider fee adjustment (write-off).

(3) Premium progressive lenses are digitally surfaced so they provide a wider reading area, less peripheral

distortion and less height restrictions than standard progressive lenses. Premium progressive lenses with higher levels of customization, including high definition lenses, are not a covered-in-full benefit; the patient is responsible for the balance between the maximum plan benefit and the provider’s usual and customary charge.

(4) The allowances are added to the lens allowance with the balance as a provider fee adjustment (write-off).

Appendix I


(5) For groups with optional tint benefits, tints other than Pink or Rose #1 or #2 are paid according to the patient’s benefit allowance. The balance of the charge for standard tints (any solid tint) exceeding the allowance is a provider write-off. The balance of non-standard tints (such as gradient and double gradient) is a patient responsibility.

(6) The contact lens allowance includes materials and may include fitting services. Contact lenses are in lieu of

other eyewear. Any difference between the allowance and the provider’s charge is a patient responsibility. To determine the appropriate benefit allowance, all contact lens claims must include the contact lens manufacturer and brand.

(7) If the patient meets criteria for medically-necessary contact lenses through the pre-approval process, the

participating provider will determine the type of contact lenses suitable to restore visual acuity based on the patient’s eye condition. When the patient elects a specific brand of contact lenses, any difference between the benefit amount and the charges will be a patient responsibility. Please see the “Limitations” section.

(8) The Provider Allowance is generally 55%-67% of the patient’s retail frame benefit amount ($60 to $750). The

difference between the provider allowance and the patient benefit amount is a provider fee adjustment (write-off). The patient is responsible for any difference between their retail frame benefit amount and the provider’s charge. Some designer frames may be restricted by the manufacturer.

(9) Sunglasses selection of $60.00 to $750.00 retail. An eligibility verification must be obtained to confirm if an eye

exam or proof of prior laser surgery is required. The difference between the provider allowance and the patient benefit amount is a provider fee adjustment (write-off). Some designer sunglasses may be restricted by the manufacturer.

(10) If the patient meets the criteria for low vision benefits through the pre-approval process, the eye care provider

will determine the type of low vision aids suitable to enhance functionality and/or quality of life. The Plan will pay for covered Subnormal/ or Low Vision testing, Low Vision Aids, and follow-up care obtained from Participating Providers up to a maximum benefit within the benefit period or lifetime benefit of $1,000.00 after a twenty-five percent (25%) deductible, if any, is paid by the Enrollee. Any difference between the allowance and the provider’s charge is a patient responsibility.

MESVision Schedule of Allowances (06-2018) 1

This schedule reflects the most common minimum and maximum compensation to participating providers of MESVision. There may be higher schedules payable for self-funded groups under ERISA. Patient-specific levels of reimbursements are available by obtaining an eligibility verification through the website, IVR, or Call Center.

SCHEDULE OF ALLOWANCES

The network Opticians, Optometrists (ODs), and Ophthalmologists (MD) accept a competitive fee-for-service schedule of allowances as payment-in-full for covered benefits.

When covered services and/or materials are provided by a participating provider, payments will be within the “High” and “Low” allowances listed below. Participating Provider allowances shall be accepted as payment-in-full unless otherwise specified in the footnotes.

Deductible Amounts: The deductible is an amount of charges for eligible vision expense you incur for which no benefits will be paid. The deductible amount will apply to services and/or materials in any 12 or 24-month benefit period for each patient.

Exam ....................................................................................................................................................... $0.00 – 50.00 Materials ................................................................................................................................................. $0.00 – 50.00

Benefit Range of Allowances

Low High

Comprehensive Examination ..................................................................................................... $ 48.00 100.00 Intermediate (Follow-up) Examination .......................................................................................... 35.00 40.00 Examination without Dilation ......................................................................................................... 35.00 60.00 Retinal Imaging .............................................................................................................................. 10.00 75.00 Contact Lens Fitting & Evaluation (7)

Standard ..................................................................................................................................... 20.00 60.00 Complex ..................................................................................................................................... 20.00 240.00

Lenses (per pair): Lenses up to 61mm ..................................................................................................................................... Included Single Vision .............................................................................................................................. 31.00 52.00 Bifocals ...................................................................................................................................... 45.00 72.50 Trifocals ...................................................................................................................................... 60.00 89.50 Standard Progressive (8) ............................................................................................................. 50.00 100.00 Premium Progressive (9) ............................................................................................................. 50.00 300.00 Aphakic/Lenticular Monofocal .................................................................................................. 125.00 125.00 Aphakic/Lenticular Multifocal .................................................................................................... 200.00 200.00 7.25 diopters or more high-powered lenses (per lens) (1) ........................................................ +13.00 +20.00Prism - 1 ½ to 4 diopters (per lens) (1) ...................................................................................... +12.50 +20.00Prism - 4 ½ to 10 diopters (per lens) (1) .................................................................................... +17.00 +25.00Slab-Off Prism (per lens) (1) ...................................................................................................... +50.00 +100.00Polycarbonate for covered children up to age 19-28

Single ...................................................................................................................................... 60.00 100.00Bi-focal .................................................................................................................................... 60.00 115.00Tri-focal ................................................................................................................................... 60.00 130.00Progressive ............................................................................................................................. 65.00 160.00Premium Progressive (9) .......................................................................................................... 65.00 360.00

Plastic Photochromic: Single ...................................................................................................................................... 75.00 155.00Bi-focal .................................................................................................................................. 110.00 175.00Tri-focal ................................................................................................................................. 115.00 190.00Progressive ............................................................................................................................. 80.00 220.00Premium Progressive (9) .......................................................................................................... 80.00 420.00

Plastic Photochromic/Polycarbonate


Single .................................................................................................................................... 100.00 200.00 Bi-focal .................................................................................................................................. 120.00 220.00 Tri-focal ................................................................................................................................. 130.00 230.00 Progressive ............................................................................................................................. 95.00 280.00 Premium Progressive (9) .......................................................................................................... 95.00 440.00

Tint (1), (4) Single ...................................................................................................................................... +8.00 +20.00 Bifocal ................................................................................................................................... +13.00 +30.00 Trifocal ................................................................................................................................... +17.00 +40.00 Pink or Rose Tint #1 or #2 ....................................................................................................................... Included Gradient ..................................................................................................................................... 5.00 20.00

Coatings Scratch ...................................................................................................................................... 2.50 10.00 Ultraviolet/UV ............................................................................................................................ 2.50 10.00 Mirrored ................................................................................................................................... 20.00 60.00 Anti-reflective

Basic .................................................................................................................................... 20.00 60.00 Premium ............................................................................................................................... 40.00 120.00 Ultra...................................................................................................................................... 60.00 180.00

Edging / Polishing ......................................................................................................................... 2.50 10.00 Contact Lenses (2):

Non-Elective/ Medically-Necessary (one pair) (3) ..................................................................... 225.00 350.00 Elective/ Cosmetic without UV Protection .................................................................................. 75.00 500.00 Elective/Cosmetic with UV Protection ...................................................................................... 100.00 550.00

Frame (6) ......................................................................................................................................... 40.00 400.00 VDT (Video Display Terminal Benefit)

Lenses: Single ...................................................................................................................................... 31.00 52.00 Bifocal ...................................................................................................................................... 45.00 72.50 Trifocal ..................................................................................................................................... 60.00 89.50 Standard Progressive (8) .......................................................................................................... 50.00 100.00 Premium Progressive (9) .......................................................................................................... 50.00 300.00

Frame (6) ..................................................................................................................................... 40.00 400.00 Plano Sunglasses (In lieu of prescription lenses and frames and/or contact lenses) (9) .............. 40.00 400.00 Low Vision Evaluation/Follow-Up/Training and Low Vision Aid (10) .......................................................up to 1,000.00 (1) The allowances are added to the lens allowance with the balance as a provider fee adjustment (write-off)

(2) The contact lens allowance ranges from $75.00 to $450.00 and includes materials and may include fitting services. Contact

lenses are in lieu of other eyewear. Any difference between the allowance and the provider’s charge is a patient responsibility. To determine the appropriate benefit allowance, all contact lens claims must include the contact lens manufacturer and brand.

(3) If the patient meets criteria for medically-necessary contact lenses through the pre-approval process, the participating provider will determine the type of contact lenses suitable to restore visual acuity based on the patient’s eye condition. When the patient elects a specific brand of contact lenses, any difference between the benefit amount and the charges will be a patient responsibility. Please see the “Limitations” section.

(4) For groups with optional tint benefits, tints other than Pink or Rose #1 or #2 are paid according to the patient’s benefit allowance. The balance of the charge for standard tints (any solid tint) exceeding the allowance is a provider write-off. The balance of non-standard tints (such as gradient and double gradient) is a patient responsibility.

(5) The Provider Allowance is generally 67% of the patient’s retail frame benefit amount ($60 to $600). The difference between the provider allowance and the patient benefit amount is a provider fee adjustment (write-off). The patient is responsible for any difference between their retail frame benefit amount and the provider’s charge. Some designer frames may be restricted by the manufacturer.

(6) The Provider Allowance for non-prescription, prefabricated (ready-to-wear) sunglasses is generally 67% of the patient’s retail frame benefit amount ($60 to $600). Plano sunglasses are in lieu of prescription lenses and frames and/or contact lenses. An eligibility verification must be obtained to confirm if an eye exam or proof of prior laser surgery is required. The


difference between the provider allowance and the patient benefit amount is a provider fee adjustment (write-off). The patient is responsible for any difference between their retail frame benefit amount and the provider’s charge. Some designer sunglasses may be restricted by the manufacturer.

(7) Standard contact lens fitting is for existing contact lens users who wear disposable, daily wear, or extended wear contact lenses. It includes two follow-up visits within three months. The standard contact lens fitting is covered in full following any applicable co-pays. Complex contact lens fitting is for a patient who has never worn contact lenses or who requires a more complex fitting for toric, gas permeable, or multi-focal contact lenses. Both standard and premium fittings may include two fitting/evaluation follow-ups within three months. Any amount over the allowance is patient’s responsibility.

(8) Standard progressive lenses (also referred to as no-line bifocals) allows the patient to see distance, mid-range and near clearly; however, there may be some peripheral distortion. Standard progressive lenses also need to be a minimum height in order to transition properly between distance and near vision. Standard progressive lenses are a covered-in-full benefit; any balance exceeding the provider’s usual and customary charge is a provider fee adjustment (write-off).

(9) Premium progressive lenses are digitally surfaced so they provide a wider reading area, less peripheral distortion and less

height restrictions, than standard progressive lenses. Premium progressive lenses with higher levels of customization, including high definition lenses, are not a covered-in-full benefit; the patient is responsible for the balance between the maximum plan benefit and the provider’s usual, customary, and reasonable charge.

(10) If the patient meets the criteria for low vision benefits through the pre-approval process, the eye care provider will determine the type of low vision aids suitable to enhance functionality and/or quality of life. The Plan will pay for covered Subnormal/ or Low Vision testing, Low Vision Aids, and follow-up care obtained from Participating Providers up to a maximum benefit within the benefit period or lifetime benefit of $1,000.00 after a twenty-five percent (25%) deductible, if any, is paid by the Enrollee. Any difference between the allowance and the provider’s charge is a patient responsibility.

The Exchange and GHP Schedule of Allowances with MOOP (03-2018)

The Exchange and Qualified Health Plans Schedule of Allowances with Maximum Patient Out-of-Pocket

The network of Opticians, Optometrists (ODs), and Ophthalmologists (MDs) accept a competitive fee-for-service schedule of allowances as payment-in-full for covered services. When covered services and/or materials are provided by a participating provider, payments will be within the “High” and “Low” allowances listed below. Participating Provider allowances shall be accepted as payment-in-full unless otherwise specified in the "Maximum Patient Out of Pocket" column and in the footnotes. We encourage you to get patient-specific levels of reimbursement via eligibility verification through the website, IVR, and Call Center. Deductible Amounts: The deductible is an amount of charges for eligible vision expenses you incur for which no benefits will be paid. The deductible amount is applied towards the allowance for covered services and/or materials in any 12 or 24 month benefit period for each patient.

Exam ........................................................................................................................................... $0.00 - $50.00 Materials ...................................................................................................................................... $0.00 - $50.00

Benefits Range of

Allowance Maximum Patient

Out-of-Pocket Maximum Provider

Reimbursement Low High Low High Low High Comprehensive Examination ............................. $57.50 $67.90 $0.00 $57.50 $67.90 Fitting & Evaluation(2) ......................................... $25.00 $60.00 $0.00 $60.00 $25.00 $60.00 Lenses (per pair):

Eye size up to 61mm ...................................... Included $0.00 Included Pink or Rose Tint #1 or #2 .............................. Included $0.00 Included Single Vision ................................................... $52.00 $0.00 $52.00 Bifocals ........................................................... $72.50 $0.00 $72.50 Trifocals .......................................................... $89.50 $0.00 $89.50 Blended Segment Multifocal ........................... $63.00 $89.50 $20.00 $83.00 $109.50 Standard Progressive ..................................... $80.00 $160.00 $55.00 $130.00 $215.00 Premium Progressive(1) .................................. $151.00 $300.00 $95.00 $241.00 $395.00 Polycarbonate for covered children up to age 18:

Single .......................................................... $45.00 $100.00 $0.00 $45.00 $100.00 Bi-focal ........................................................ $68.00 $115.00 $0.00 $68.00 $115.00 Tri-focal ....................................................... $76.00 $130.00 $0.00 $76.00 $130.00

Polycarbonate (Adults, monocular or prescription > + / -6.00 diopters): Single .......................................................... $45.00 $100.00 $30.00 $75.00 $130.00 Bi-focal ........................................................ $68.00 $115.00 $30.00 $98.00 $145.00 Tri-focal ....................................................... $76.00 $130.00 $30.00 $106.00 $160.00

Progressive/Polycarbonate(1) $80.00 $180.00 $50.00 $120.00 $130.00 $300.00 Glass Photochromic(1)

Single .......................................................... $87.00 $155.00 $20.00 $107.00 $175.00 Bi-focal ........................................................ $126.00 $175.00 $20.00 $146.00 $195.00 Tri-focal ............

Documents

Participating Provider Manual - MESVision · 1994. 10. 15. · discount on non-covered benefits. MES represents participating providers with a choice of all three eye care professionals