Coordination of Benefits – Why Make the Effort?

Miller 968Jason R. Miller, OD, MBA, FAAO – Please note: The following column is based on my experience and not an official opinion of the OOA. Every optometrist must decide how to handle this issue.

Are you confused about how to bill your diabetic patients? Especially your diabetic patients who also have VSP? Many health care payers have sent notices to many eye care providers asking for the claim when their member is diabetic. It’s kind of a blessing and a curse when two different carriers are asking for the claim with these specific patients. For example, this letter recently arrived in my office from Medical Mutual:

MedMut Form




These letters are correct when determining who to send the claims to, but need some clarification when it comes to actually submitting the claims and the order in which they are processed. There can be some confusion, as most vision insurances will not accept Refraction Only claims.

Determining who gets the bill starts with the reason for the visit. The patient’s reason for the visit should determine who gets the bill. If it is a refractive complaint (Myopia, Presbyopia, etc.), the vision plan should receive the bill for the encounter. If is a medical complaint (Diabetes, Dry eyes, Allergic Conjunctivitis, etc.), the medical insurance should get the bill for the encounter. That reason for the visit can be either a patient complaint or an order from the doctor at their previous visit (for example: Order Procedure: Glaucoma Work-Up in three months). That order from their previous encounter becomes the reason for the visit when they come in for that testing.

Typical Scenario:

If the patient is diabetic, they may be in for new glasses or contact lenses and their annual diabetic exam as prescribed by their primary care physician or endocrinologist. One possibility is to provide their vision exam (submit to vision) and have them back for any diabetic testing (submit to medical). That is typically not very patient-centric, as we can usually provide this service at the same time and will save the patient a trip to our office. This article details steps to take in order to coordinate the patient’s visit between both their Medical and VSP when appropriate.

  1. To coordinate this claim to VSP, there must be a refraction done on the same date as well.
  2. The exam can be either a 99xxx or 92xxx CPT, whichever you deem appropriate. The medical exam needs to be pointed to the medical diagnosis (choose a Diabetic code in this scenario – 250.xx) listed in position 1 on the HCFA form.
  3. The refraction (92015) must be pointed toward a refractive diagnosis.
  4. The claim, in its entirety with the exam, refraction and any special testing if applicable (92250 Fundus photos if medically necessary), will be filed to the health insurance carrier for consideration.

Note: You do not have to collect any co-pays at this visit.

The health insurance is going to process the claim as primary and they are going to pay based on the patient’s coverage for that service. Once the health insurance processes the claim, you will receive the explanation of payment (EOP). After the health insurance company processes the claim as primary, the claim can then be filed to VSP under their coordination policy.

Keep in mind that this secondary claim to VSP must mirror the primary claim exactly. This is not just sending the refraction code to VSP. The CPT codes and diagnosis order cannot be altered.

Once VSP gets the secondary claim, they will pay up to $66 on Signature or Choice plans, less the copay amount per the patient’s plan. VSP will not pay on any testing overages the primary does not cover. They will only pay on the exam and refraction overages that the health insurance carrier does not pay.

COB Max COB Payment for all states as of 04/01/13:






Let’s say they have a $30 copay from the medical insurance and the $XX refraction is non-covered. Per the health plan, the patient’s total out of pocket should be $30 + $XX for the refraction.

Next steps – this is taken directly from the VSP Coordination Policy (click on the link for the policy):

For Paper Claims:

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

For Electronic Claims:

  • When you receive payment from the health plan, keep a copy of the original CMS-1500 form showing the exam and refraction services submitted to the health plan, along with the Explanation of Payment or Explanation of Benefits from the health plan/Medicare, in the patient’s file.

After the claim is submitted to VSP as secondary and when VSP considers the claim, they are willing to pay up to $66 ($66 less the $XX VSP copay) as secondary. Of the $30 + $XX balance that is outstanding from primary, VSP will cover their portion and the patient responsibility will be what is left, if anything.

Please Note: There is no VSP write-off when VSP is acting as secondary. The primary health insurance allowable will be honored, but VSP requires no additional write-off on a medical coordination; it is a flat benefit amount as secondary.

Explaining this to the patient can also be a challenging situation, but Dr. Neil Gailmard just had a very good practice management explanation of this situation along with a handout to use with patients. I have copied and pasted this explanation from his post, but you can also access this online at:

Optometric Management Tip # 561 – Wednesday, December 05, 2012

A Patient Handout for Vision vs. Medical. In last week’s article, I provided an overview of the differences between vision plans and medical insurance. If your practice routinely bills all eye exams to vision plans, you may want to consider differentiating medical eye exams from routine vision exams and billing the former to medical insurance plans. 

The difficult part of this process is educating patients about the differences. That requires significant staff training, but a patient handout like the one below can be a big help. Feel free to modify the form below to describe your office policies. The handout can be given to patients at check-in or check-out and it serves as a guide for staff members as they speak to patients over the phone. I find it is best to keep educational handouts short and simple. Many patients simply will not read a form if it is long and wordy.

***Sample Handout***

About Your Insurance. There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both: 
Vision care plans (such as VSP and EyeMed)
Medical insurance (such as Blue Cross/Blue Shield and Medicare).

Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance must be used if you have any eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

I have read and agree with these policies.

________________________            __________

Patient signature (parent if child)                Date

Please provide your insurance cards to our staff member.

Best wishes for continued success,

Dr. xxx, O.D.

A special thanks to my business partner, Dr. Tamara Kuhlmann, OD, MS, FAAO, and Branda Barton of Optometric Billing Solutions for their assistance with this article.

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