EmblemHealth Provider Manual Subject: Chapter - Vision Services Created Date: 20190913022314Z ...
FINDING A PARTICIPATING EYEMED VISION PROVIDER. PARTICIPATION WITH EYEMED. BILLING AND CLAIMS PAYMENT. Back to Table of Contents.
VISION SERVICES TABLE OF CONTENTS .A.F. F. .E.C. .T.E. .D. .M. .E. M. . B. .E. R. .S.H. .I.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .0.8. . . .F.I.N. D. .I.N. .G. .A. .P. A. .R. T. .IC. .I.P.A. .T.I.N. G. . .E.Y. .E.M. .E. D. . .V. I.S.I.O. .N. .P. R. .O. .V. I.D. .E.R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .0.8. . . .P.A. R. .T. I.C. .IP. .A.T. .IO. .N. . W. . .IT. .H. .E. Y. .E.M. . E. .D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .0.9. . . .B.I.L.L.I.N. .G. .A. N. .D. . C. .L. A. .I.M. .S. P. .A. Y. .M. .E. N. .T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .0.9. . . Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 607 VISION SERVICES The EmblemHealth Vision Program, developed with EyeMed, provides routine vision management for all EmblemHealth members that have a routine vision and materials benefit. Please note that not all members have a routine vision benefit. EyeMed will administer all routine exams (to determine if corrective lenses are required) and the dispensing of hardware such as frames, lenses and contact lenses based on the member's benefit. EyeMed is responsible for the provider network including contracting and credentialing, claims processing and payment, routine vision grievances and claims appeals.* *Exception: Medicare grievances and claim appeals will continue to be managed by EmblemHealth. AFFECTED MEMBERSHIP EyeMed is the vision services provider for all EmblemHealth members with a vision care benefit. This includes ASO members whose vision benefit is managed by EmblemHealth. Please note not every EmblemHealth member has a routine vision benefit. See the member's Benefit Summary on emblemhealth.com or call EyeMed to determine if a member has vision coverage. Included Membership 1. Medicaid 2. Medicare 3. HIP (including members whose care is managed by Montefiore Medical Group (CMO) or HealthCare Partners (HCP) and members who selected a PCP assigned to a St. Barnabas Hospital System PCP or AdvantageCare Physicians (ACPNY).) 4. GHI Commercial Groups with Vision Benefits (See the eligibility information on emblemhealth.com or call EyeMed to determine if a GHI member has vision coverage.) FINDING A PARTICIPATING EYEMED VISION PROVIDER If your patients previously got their vision benefits from Davis Vision (a.k.a.VisionWorks), GVS, EyeCare Advantage or an independent in-network provider, starting January 1, 2017, they must use an in-network EyeMed provider in order to get covered benefits (in accordance with their benefit plan. Participating EyeMed providers can logon onto https://www.eyemed.com or contact EyeMed customer Service at 1-888-581-3648 to obtain member eligibility and benefit information. For help finding an in-network EyeMed provider, and to ask about benefits, please share the following EyeMed Customer Service toll-free numbers with your patients: 1-844-790-3878 Medicare 1-877-324-2791 Medicaid 1-877-324-4063 Commercial (HMO, PPO, POS) 1-877-324-6211 On/Off Individual and and Essential Plans Group Exchange TTY/TDD:711 Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 608 PARTICIPATION WITH EYEMED VISION SERVICES Information for Vision Service Providers EyeMed is responsible for the provider network including contracting and credentialing, claims processing and payment, routine vision grievances and claims appeals.* *Exception: Medicare grievances and claim appeals will continue to be managed by EmblemHealth. If you are Interested in Joining EyeMed Complete an online interest form found at forms-engine.com/eyemed/NewProviderDirect.html or call EyeMed's provider service department at 1-800-521-3605. BILLING AND CLAIMS PAYMENT Routine Vision Exam CPT Codes, Materials HCPCS, and Diagnosis Codes Routine vision exam CPT codes, materials HCPCS, and diagnosis codes that should be billed to EyeMed are listed below. Claims submitted to EmblemHealth will be denied. CPT CODE 92002 92004 92012 92014 92015 V2750 V2750-21 V2750-22 V2750-25 V2750-TG S0500 V2500 V2503 V2510 V2513 V2520 V2523 V2530 V2531 V2599 V2020-V2025 V2700 V2702 V2702-TG V2710 V2715, V2715U1, V2715U3, V2715U4 V2718, V2718U1, V2718U3, V2718U4 V2730 V2744, V2744U1, V2744U2 V2744U5, V2744U6, V2744U7, V2744U8 V2745, V2745UA, V2745UB, V2745UC V2755 V2760, V2760-22, V2760-TG V2761 V2762 V2770 V2780 V2782 DESCRIPTION Intermediate Comprehensive Intermediate Comprehensive Refraction Standard A/R A/R Tier 3 A/R Tier 1 A/R Tier 2 Premium A/R Disposable Contact Lenses PMMA Gas Permeable Hydrophilic Scleral Other Contact Lenses Deluxe Frame Balance Lens, Glass or Plastic Edge Treatment (Polish or Roll) Faceting Slab-Off Prism Prism Fresnell Prism Special Base Curve Photochromic plastic (Transitions®) Photochromic Tint, Solid or Gradient UV Lens Scratch-Resistant Coating Mirror Coating Polarization Occluder Lens Oversize Lens Mid-Index (1.56) Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 609 V2783, V2783U1, V2783U3, V2783U4 Hi-Index (1.60+) V2100 V2118, V2410, V2410-22 Single Vision Lens V2121, V2221, V2321 Lenticular V2200 V2220, V2299, V2430, V2430-22 Bifocal Lens V2300 V2320, V2399 Trifocal Lens V2781 Plans without Fixed Pricing by Tier - Standard Progressive V2781 S0581 Premium Progressive - Must include modifier V2781 S0581 Progressive Tier 4 - Must include modifier V2781-22 Progressive Tier 2 V2781-25 Progressive Tier 3 V2781-TG Progressive Tier 1 V2784 Polycarbonate Standard V2784-22 Premium Polycarbonate ICD 10 CODES H52 H.52.0 H52.00 H52.01 H52.02 H52.03 H52.1 H52.10 H52.11 H52.12 H52.13 H52.2 H52.20 H52.201 H52.202 H52.203 H52.209 H52.21 H52.211 H52.212 H52.213 H52.219 H52.22 H52.221 H52.222 H52.223 H52.229 H52.31 H52.32 H52.4 H52.51 H52.511 H52.512 H52.513 H52.519 H52.52 H52.521 H52.522 H52.523 H52.529 H52.53 H52.531 H52.532 H52.533 H52.539 H52.6 H52.7 H53.0 H53.00 H53.001 H53.002 DESCRIPTION Disorders of Refraction and Accomodation Hyperopia Hyperopia, unspecfied eye Hyperopia, right eye Hyperopia, left eye Hyperopia, bilateral Myopia Myopia, unspecified eye Myopia, right eye Myopia, left eye Myopia, bilateral Astigmatism Unspecified astigmatism Unspecified astigmatism, right eye Unspecified astigmatism, left eye Unspecified astigmatism, bilateral Unspecified astigmatism, unspecified eye Irregular Astigmatism Irregular Astigmatism, right eye Irregular Astigmatism, left eye Irregular Astigmatism, bilateral Irregular Astigmatism, unsecified eye Regular Astigmatism Regular Astigmatism, right eye Regular Astigmatism, left eye Regular Astigmatism, bilateral Regular Astigmatism, unsecified eye Anisometropia Aniseikonia Presbyopia Internal ophthalmoplegia Internal ophthalmoplegia, right eye Internal ophthalmoplegia, left eye Internal ophthalmoplegia, bilateral Internal ophthalmoplegia, unspecified eye Paresis of accommodation Paresis of accommodation, right eye Paresis of accommodation, left eye Paresis of accommodation, bilateral Paresis of accommodation, unspecified eye Spasm of accommodation Spasm of accommodation-right eye Spasm of accommodation-left eye Spasm of accommodation-bilateral Spasm of accommodation-unspecified eye Other disorders of refraction Unspecified disorders of refraction Ambyopia Unspecified amblyopia Unspecified amblyopia, right eye Unspecified amblyopia, left eye VISION SERVICES Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 610 H53.003 H53.009 H53.01 H53.011 H53.012 H53.013 H53.019 H53.02 H53.021 H53.022 H53.023 H53.029 H53.03 H53.031 H53.032 H53.033 H53.039 H53.10 H53.14 H53.141 H53.142 H53.143 H53.149 Unspecified amblyopia, bilateral Unspecified amblyopia, unspecified eye Deprivation amblyopia Deprivation amblyopia, right eye Deprivation amblyopia, left eye Deprivation amblyopia, bilateral Deprivation amblyopia, unspecified eye Refractive amblyopia Refractive amblyopia, right eye Refractive amblyopia, left eye Refractive amblyopia, bilateral Refractive amblyopia, unspecified eye Strabismic amblyopia Strabismic amblyopia-right eye Strabismic amblyopia-left eye Strabismic amblyopia-bilateral Strabismic amblyopia-unspecified eye Unspecified subjective visual disturbances Visual Discomfort Visual Discomfort, right eye Visual Discomfort, left eye Visual Discomfort, bilateral Visual Discomfort, unspecified eye VISION SERVICES Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 611EmblemHealth Services Co., LLC via ABCpdf