Billing

1. Bill all claims for vision care items and services to PrimeWest Health using the appropriate claim format.
   1. Independent clinics/facilities providing optical services: bill claims for covered services to PrimeWest Health using the 837P claim format.
   2. Provider based clinics providing vision care services: bill eyewear on the 837I claim format and bill professional services on the 837P claim format.
2. Each line item submitted charge must reflect the provider’s U&C charge.
3. Bill frames, lenses, dispensing fee, repairs, and other covered items and services using HCPCS (Level I and II) codes and guidelines.
   1. Fitting codes 92340 – 92342 should only be included on the claim when billing for a complete set of glasses (frame and two lenses).
   2. Claims for lenses only or replacement of frames (V2020 or V2025 with the RA modifier) cannot be billed with a fitting code.
   3. Bill repairs to frames using either code 92370, repair and refitting of spectacles, or 92371, repair of spectacle prosthesis for aphakia. These codes will not require any additional modifiers. Do not bill a dispensing code for repairs.
4. When billing for two of the same lens codes, either bill one service line with two units and no modifier or two lines with the appropriate RT and LT modifiers.
5. Include the appropriate International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM) diagnosis code on the claim. Examples of situations that should be noted in the diagnosis include the following:
   1. A medical condition that requires either tinted or photochromatic lenses
   2. Aphakia, keratoconus, or aniseikonia that requires contact lenses
   3. Allergic reaction to previous frame that requires new frames
   4. Medical condition that requires an aspherical hand-held magnifier (3.7 X 11.0 diopter)
   5. Medical condition that requires Fresnel prism, slab off prism
6. Date of service
   1. The date of service for the dispensing fee is the date the eyeglasses are delivered to the member.
   2. The date of service for frames and lenses is the date the eyeglasses were ordered.

Copays

Eyeglasses (complete frames and lenses) may be subject to a copay. A copay does not apply to eyeglass repairs or if only the frames are dispensed or only the lenses are dispensed. Review the member’s benefits to determine whether the member is subject to a copay.

Billing the Member

The member may purchase non-covered add-ons and non-covered items. Add-ons are lens treatments that can be added to a pair of covered lenses and frames. Examples are: lens coating, special edge treatments, scratch resistant coating, anti-reflective lens coating, etc. Members may pay for the cost only of the add-on products. The provider must inform the member before providing the item that it is not covered by PrimeWest Health and that the member is responsible for the payment of the add-on item.

Members may be billed for non-covered items. If a member chooses to purchase upgraded lenses that are not medically necessary (such as high-index plastic, transition lenses, no-line bifocals) or an upgraded frame that is not medically necessary (such as a more fashionable frame), the member is responsible for payment of the entire cost. The provider cannot bill the member for the difference between covered lenses or frame and the upgraded lenses or frame. PrimeWest Health will not pay for the dispensing fee, repairs or adjustments made to upgraded products or non-covered items.

Maximum Allowable Rates

Providers must bill PrimeWest Health at their U&C charge. PrimeWest Health will pay the lower of the submitted charge or the maximum allowable rate.

PW_11-19_575
Updated_05/17/2021