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Advantica Routine Vision Provider Manual Advantica Administrative Services, Inc. Address: 12399 Gravois Road St. Louis, MO 63127 Phone: (866) 354-2020 Fax: (727) 683-8810 Email: [email protected] Web: www.advanticabenefits.com

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Advantica Routine Vision Provider Manual

© 2018 Advantica. All rights reserved. 2

Table of Contents ADMINISTRATIVE OFFICE INFORMATION ............................................................................................................ 3

General Contact Information ......................................................................................................................... 3 Telephone, Fax, Email ..................................................................................................................................... 3

ADVANTICA VISION BENEFITS .............................................................................................................................. 4 SELECT PLUS PLANS ........................................................................................................................................ 4

ADVANTICAVALUE DISCOUNT PROGRAM ............................................................................................................ 6 NETWORK MANAGEMENT – CREDENTIALING ..................................................................................................... 7 APPEAL OF CREDENTIALING RECOMMENDATIONS ............................................................................................. 8 PROVIDER RIGHTS ................................................................................................................................................ 8 CHANGE OF INFORMATION NOTIFICATION ......................................................................................................... 9 WITHDRAWING FROM THE ADVANTICA NETWORK ............................................................................................ 9 MEMBER ELIGIBILITY ............................................................................................................................................ 10

Verifying Eligibility .......................................................................................................................................... 10 Member Identification Cards ......................................................................................................................... 10 Eligibility Verification Online .......................................................................................................................... 11 Eligibility Verification via IVR (Interactive Voice Response) System .............................................................. 13 Eligibility Verifications by Phone .................................................................................................................... 13

CLAIM SUBMISSION GUIDELINES ......................................................................................................................... 14 Electronic Submission ..................................................................................................................................... 14 Paper Submission ........................................................................................................................................... 14 Required Data Elements ................................................................................................................................. 15 Submitting Claims Online ............................................................................................................................... 17

COORDINATION OF BENEFITS .............................................................................................................................. 20 BENEFIT REINSTATEMENT FORM ......................................................................................................................... 20 CLAIMS TIMELY FILING LIMITATION ..................................................................................................................... 20 DIAGNOSIS CODES ................................................................................................................................................ 20 CPT CODES ............................................................................................................................................................ 22 PROVIDER APPEALS .............................................................................................................................................. 25 MEMBER APPEALS AND GRIEVANCES .................................................................................................................. 25 FRAUD WASTE AND ABUSE .................................................................................................................................. 26



Administrative Office Information General Contact Information Corporate Address: 12399 Gravois Road, St. Louis, MO 63127 Advantica Website: www.advanticabenefits.com Paper Claims Address: PO Box 981607, El Paso, TX 79998-1607 Electronic Claims Submission: RedCard EFT/ERA Payer ID 59374 Corrected Claim Submission: Attention: Special Handling PO Box 8510, St. Louis, MO 63126 Or Fax to (314) 849-4830 or (800) 501-8432 Credentialing: Advantica-Credentialing 380 Park Place Blvd, Suite 150 Clearwater, FL 33759 Provider Appeals: Advantica-Appeals Department PO Box 8510 St Louis, MO 63126 Telephone, Fax, Email Customer Service: Phone: (866) 425-2323 Fax: (314) 849-4830 or (800) 501-8432 Hours: Monday - Friday 7 a.m. to 6:00 p.m. CST Network Management: Phone: (866) 354-2020 Fax: (727) 683-8810 Email: [email protected] Credentialing: Phone: (727) 683-8832 Fax: (727) 712-2200 Email: [email protected] Provider Appeals: Email: [email protected]

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Advantica Vision Benefits SELECT PLUS PLANS Eye Exam Benefit: Members are eligible to receive one (1) routine eye exam per plan year. No referral is required; however, please verify eligibility in advance (see Verifying Eligibility, page 10). Use the Diagnosis and CPT codes listed on pages 20-24, when billing a routine eye exam for an Advantica member. Advantica considers a refraction part of the routine exam and does not pay for refraction separately. If refraction (92015) is submitted, it will be bundled with the routine exam. Providers shall be available to see members for routine vision exams within thirty (30) calendar days. A complete annual eye exam must include the following components: Patient’s personal and family history Visual acuity Manifest refraction Intraocular pressures Biomicroscopy findings Fundus evaluation with pupil dilation on all initial examinations and subsequently based on medical

necessity and member request. The following is a partial list of services and materials which are excluded from coverage under the Advantica routine vision plan: Medical and surgical treatment of the eyes Post cataract refraction or lenses Non-prescription lenses including sunglasses Replacement of lost lenses and/or frames Orthoptics or vision training Low-vision aids Services or materials provided covered under workers’ compensation law Services or materials provided by self or an Immediate Family Member Any eye examination required by an employer as a condition of employment Two pair of glasses in lieu of bifocals or trifocals Experimental or non-conventional treatment or devices



Eyeglasses: Advantica Plans include a retail frame allowance, starting at $100. Providers must have a selection of frames available that, with CR-39 lenses in Single Vision, Bifocal or Trifocal lenses are covered with no additional out-of-pocket expense to the member beyond the co-payment. The selection should include frames for men, women and children. If a member chooses a frame with a retail value in excess of the frame allowance, then the member is responsible for the difference between the frame’s retail value and the allowance amount. Additional discounts may apply. (See AdvanticaValue Discounts Program, page 6). Please be sure that the member understands their financial responsibility in advance. Standard Polycarbonate Lenses: Available in lieu of CR-39 at no additional cost to members of age 19 and under. Standard Progressives/Photochromic Lenses: Members are able to purchase standard progressive and/or photochromic lenses in CR-39 for additional co-payments in addition to their standard material co-payment. Contact Lenses: Advantica plans include a retail allowance for the purchase of contact lenses, which members may use in lieu of their prescription eyeglass benefit. The member is responsible for the difference between the retail cost of the contact lenses and the allowance amount. This benefit is paid only once within the frequency period and must be fully utilized at that time. The member also receives a separate allowance toward a contact lens fitting, and is responsible for paying the balance. Medical Eye Care: Please note the only medical eye care services covered under the plans is medically necessary contact lenses. Medically Necessary Contact Lenses: Medically Necessary Contact Lenses require pre-authorization. Please complete the Additional Exam & Benefit Request Form and submit it via fax to Customer Service number listed on the form to obtain pre-authorization. This form is available by visiting the Advantica website at www.advanticabenefits.com, and clicking on the PROVIDERS tab, and scroll to the FORMS. This benefit is available in lieu of eyeglasses and standard contact lenses for members who cannot obtain functional vision unless contact lenses are used (ex. Keratoconus, Aphakia or Severe Anisometropia). The member pays the materials co-payment plus any amounts in excess of material and contact lens fitting benefits. A relevant diagnosis must be listed as the primary diagnosis on the claim. This benefit does not apply to bandage contact lenses. Providers must submit a paper claim with a copy of the lab invoice with the material cost circled. If approved, reimbursement will be based on the invoice amount plus 20% up to a maximum allowance of $250.00. Mail the claim to Advantica marked “Special Handling” for processing. Advantica P.O. Box 8510 St. Louis, MO 63126

https://www.advanticabenefits.com/PDFs/AdvanticaBenefits/DocManagement/Medically-Necessary-Contact-Form-05-2016fo9_53151_12_05_2016.pdf





AdvanticaValue Discount Program The AdvanticaValue Discounts program is a value-added addition to the PPO product. If you are an AdvanticaValue Discounts Provider, you have agreed to accept the discounts noted below as payment in full. Your practice will be prominently noted with a blue star in our online directory. Please note, there will be no corresponding reimbursement from Advantica for these items, which are simply discounts available to the members and are not part of the insurance benefit.

Service / Materials Member Cost Second Exam

(after insurance benefit is exhausted) 10% off Retail Price

Contact Lens Fit and Follow Up (after insurance benefit is exhausted) 15% off Retail Price

Contact Lenses (after insurance benefit is exhausted) 10% off Retail Price

Insurance* Frame Upgrades 15% off Retail Price over Frame Allowance Additional Frame(s)

(after insurance benefit is exhausted) 20% off Retail Price

Single Vision Lenses (after insurance benefit is exhausted) Standard $50

Bifocal Lenses (after insurance benefit is exhausted) Standard $70

Trifocal Lenses (after insurance benefit is exhausted) Standard $105

Progressive Lenses (after insurance benefit is exhausted) Standard $155

Insurance* Premium Lens Upgrade 20% off the difference between retail value of the premium lens option and standard lens option

Premium Lens Upgrade (after insurance benefit is exhausted) 20% off Retail Price

Polycarbonate Lenses Standard $30

Polarized Lenses $70

Ultra Violet Coating $16

Tint Solid/Gradient $16

Scratch Coating Standard $16

Anti-Reflective Coating Standard $45

Drill Mount $29

Lens Grooving $19

Edge Polish $15

Other Lens Options and Materials 20% off Retail Price * Insurance Upgrades: When a member purchases a lens or frame upgrade in conjunction with an insured benefit, the

stated discount applies to the difference between the retail value of the premium option and the retail value of the standard option covered by the insurance benefit.



Network Management – Credentialing All providers are required to be credentialed and approved by Advantica prior to inclusion in the Advantica network. Advantica has the sole discretion to determine which providers it shall accept in its network as Participating Providers. The credentialing process provides a general guide for evaluation of new providers for acceptance, as well as, discipline and termination of Participating Providers, and includes two components: a) initial credentialing and b) re-credentialing every three (3) years after the provider’s initial credentialing date. In the event a new provider joins your practice, please contact Advantica Provider Relations for a provider application and agreement so that the new provider may be credentialed as soon as possible. Advantica provider relations can be reached at (866) 354-2020 or [email protected]. To facilitate the credentialing process, Advantica uses CAQH Proview. Please make sure that your CAQH file includes an updated attestation and current copies of the required documents listed below: A signed and dated credentialing application with all fields completed. (Note: Where required, the

provider must use his or her state’s mandated credentialing application.) A copy of the provider’s DEA or CDS certificates, as applicable The declaration page from the provider’s professional liability insurance policy, unless covered under

sovereign immunity Complete work history - minimum of the last five (5) years or from last date of graduation with a written

explanation of any gaps of six (6) months or more Advantica Provider Participation Agreement, Plan Participation Form, and W9

Providers will be notified of a credentialing decision within 180 days of receipt of a complete application, unless otherwise required by state law. Providers will be notified via email or fax of any missing items or incomplete information. If claims are submitted prior to receiving notice of acceptance into the Advantica network, such claims will be adjudicated as out-of-network. If you provide care or services for Advantica members prior to being accepted in the network, please advise the members to submit a Vision Member Reimbursement Request Form. Once your Advantica Welcome Letter is sent, services rendered after that date will be adjudicated as in-network claims, and you will be responsible for submitting the claims on the member’s behalf. During the initial credentialing process and following acceptance into the network; it is your responsibility to report any changes to the information you initially submitted on your credentialing application via email [email protected] including the following: Malpractice insurance carrier or coverage amounts Status with the licensing board in any jurisdiction Status with Medicare and/or Medicaid programs


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Appeal of Credentialing Recommendations If the Credentialing Committee recommends denial of an application or termination of participation, the provider shall have the right to appeal the denial or termination. To do so, the provider must file the appeal in writing within thirty (30) days of receipt of the notice, see page 6 for contact information. The provider may choose to be represented by an attorney or other person of the provider’s choice, and the review panel’s decision will be rendered within thirty (30) days of receipt of the appeal.

Provider Rights You have the right to request and receive the status of your Credentialing Application. You have the right to inspect data Advantica collected about you during the Credentialing process, which is

not protected by Peer Review regulations. You have the right to correct erroneous information Advantica collected about you during the

Credentialing process, which is not protected by Peer Review regulations. You have the right to request copies of Advantica’s Credentialing Policies and Procedures, and to make

recommendations regarding the Credentialing Program, Policies and Procedures. Credentialing Department Contact Information is listed below: Phone: (727) 683-8832 Fax: (727) 712-2200 Email: [email protected] Mail: Advantica Administrative Services, Inc. Attention: Credentialing Department 380 Park Place, Ste. 150 Clearwater, FL 33759

Electronic Funds Transfer (EFT) Advantica partners with RedCard Systems – a solution that delivers Electronic Funds Transfers (EFTs), Electronic Remittance Advice (ERAs)/Vouchers, and much more. This service is free to Advantica providers. The solution enables online notification of remittance/vouchers and straightforward reconciliation of payments to empower network providers to reduce costs, and speed secondary billings, improve cash flow, and help the environment by reducing paper usage. Signing up for electronic payments is simple, secure, and will only take 10-15 minutes to complete. To complete the registration process, please visit the RedCard website at https://enroll.ach835.com or contact them directly at (844) 292-4066. A step by step instruction is available at www.advanticabenefits.com -> click on Providers tab and then click on Electronic Payments on the right hand side.


https://enroll.ach835.com/quickclaim/servlet/quickclaim/template/ClearingHouse,ProviderInvitation.vm

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Change of Information Notification Please take the time to review your practice information in our online provider directory at www.advanticabenefits.com (click on Provider Search). If any of the information included about your practice is out of date, please complete and submit an Information Change Form to the Advantica provider relations department by e-mail at [email protected]. Information Change Forms are available by visiting the Advantica website at www.advanticabenefits.com, click the PROVIDERS tab, and scroll to the FORMS. The following changes should be submitted via an Information Change Form: Change of Tax-ID of an office location which Advantica has on file. You must also complete and file a current

W-9 with Advantica. Office address change (relocation or addition or deletion of an office location). Mailing or billing address change of an office location which Advantica has on file. Deletion of a provider in your practice.

For all other changes, please contact Provider Relations directly at [email protected] or 866-354-2020.

Withdrawing from the Advantica Network If you would like to terminate your participation with Advantica, please notify us in writing via certified U.S. mail, or by commercial overnight delivery to the address below. The time period for such notice is stated in the provider agreement you entered into with Advantica. Please note: It is your responsibility to notify our members of the change in your status. To ensure continuity of care, you are required to continue providing Covered Services to Members for ninety (90) days following the termination of your participation with Advantica, or longer if required by state law. Please send communications or notifications to: Mail: Advantica Administrative Services, Inc. Attn: Network Management 380 Park Place, Suite 150 Clearwater, FL 33759-4928 Fax: (727) 683-8810

https://www.advanticabenefits.com/Members/Provider_Search_Form?planType=Vision


https://www.advanticabenefits.com/PDFs/AdvanticaBenefits/DocManagement/Provider%20Information%20Change%20Formfo9_51896_03_05_2016.pdf






Member Eligibility Verifying Eligibility Member eligibility must be verified with Advantica. Eligibility can be verified on the provider portal online, through our IVR automated telephone voice response system, by phone or fax. Note: Due to eligibility and enrollment status changes, this information does not guarantee payment and is subject to change. The member must also be eligible at the time of service. Member Identification Cards Below is a sample membership card to help you identify the employees covered by Advantica and DeltaVision®, which uses the Advantica Network.

DeltaVision® uses the Advantica Network. It is underwritten by Advantica Insurance Company, and administered by Delta Dental of Missouri and Advantica Administrative Services, Inc.



Eligibility Verification Online Have the practice’s username and password ready. Log on: www.advanticabenefits.com Click on the Providers tab on the website navigation toolbar and then Provider Login.

Click here to access the portal directly or visit: https://www.advanticabenefits.com/Providers/Login Prompts will appear, requesting a username and password. Enter your assigned information and press

“Login.” Once logged in, use the Toolbar located on the left side of the page to navigate the website. To check

eligibility, simply click on the “View Plan/Benefit Information” button found on the toolbar. Member Information: Enter the Subscriber ID or Alt ID (located on the front of the ID card), last name and

date of birth. Once the search results are returned, click on the icon in the Action column, from there you can check co-payment for the member under Coverage Levels. Eligibility date can be checked under Previous Services. No authorizations are required for covered benefits, except Medically Necessary Contact Lenses. Please ensure you are using the latest versions of Internet Explorer, or Chrome only. Firefox is not compatible at this moment.


https://www.advanticabenefits.com/Providers/Login




Coverage Levels: Exam and materials co-payments are displayed, as well as the material allowance.



Previous Services: This section will provide the Next Available Date the member is next eligible for

services. If there are any previous services performed for the member, it will be listed under the Previous Services section.

Eligibility Verification via IVR (Interactive Voice Response) System Dial: (866) 425-2323 Have the Following Information Ready: Provider’s 10 digit Individual NPI (National Provider Identifier) number Subscriber’s ID number as listed on the insurance card Subscriber’s Last Name Patient’s Date of birth

Eligibility Verifications by Phone A customer service representative can also verify member eligibility. To reach our customer service department, simply call (866) 425-2323 during our regular business hours (Monday through Friday: 7:00 a.m. to 6:00 p.m. central time).



Claim Submission Guidelines Providers may submit claims to Advantica in one of the following formats: Electronic claims via your clearinghouse Paper submission on a CMS 1500 form Electronic claims via Advantica’s online provider portal

The following guidelines apply to all claims regardless of submission method: A reference number is not required in order to submit claims to Advantica. If your system requires a

reference number you may enter the date in which you verified the member’s eligibility. The eligibility verification does not guarantee payment of claims submitted. The member must also be

eligible at the time of service and the date the claim is submitted to Advantica. No medical diagnosis code will be paid if it is selected as primary diagnosis code for the service(s). For the list of Diagnosis Codes and CPT Codes, see pages 20-24; no modifiers are required. When billing for lenses, the correct number of UNITS must be identified on the claim form. If no units are

listed, only ONE lens will be paid. Please enter 1 unit for exam and frame procedure codes, and enter 2 units for lenses or contact lenses.

Benefit payments and, Remittance Advices (RAs) are issued by Advantica on a weekly basis. Providers can also be paid electronically via Electronic Funds Transfer (EFT). This service is free for our

providers and is available through RedCard EFT/ERA.

Electronic Submission Providers may submit claims electronically using Advantica’s website (see online claim section) or an electronic clearinghouse using the payer ID below. Please include all of the Required Data Elements on pages 15-16 in order to submit a clean claim. A clean claim is a claim received with all information necessary to adjudicate successfully. If data elements are not completed, the claim may be denied. Payer ID: 59374

Paper Submission Providers may mail (CMS 1500 form) claims to the following address:

Advantica P.O. Box 981607 El Paso, TX 79998-1607

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The following information, when applicable, must be included on a claim to be accepted as a clean claim. A clean claim is a claim received with all information necessary to adjudicate successfully. If data elements are not completed, the claim may be denied. Required Data Elements Advantica requires that paper claims be submitted on the current CMS Form 1500. If data elements are not completed, the claim may be denied. Please see next page for list of required data elements.

BLOCK DESCRIPTION 1 a SUBSCRIBER’S ID NUMBER 2 PATIENT’S NAME 3 PATIENT’S BIRTH DATE AND SEX 4 SUBSCRIBER’S NAME 5 PATIENT’S ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP AND PHONE NUMBER) 6 PATIENT’S RELATIONSHIP TO INSURED 7 SUBSCRIBER’S ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP AND PHONE NUMBER) 8 PATIENT STATUS 10 a, b, c PATIENT’S CONDITION RELATED TO (ANY THAT APPLY) 11 SUBSCRIBER’S POLICY GROUP OR FECA NUMBER 11 a SUBSCRIBER’S BIRTH DATE AND SEX 11 c INSURANCE PLAN NAME OR PROGRAM PLAN NAME 11 d OTHER HEALTH BENEFIT PLAN (IF YES, COMPLETE 9A-9D) 12 PATIENT OR AUTHORIZED PERSON’S SIGNATURE 13 SUBSCRIBER’S OR AUTHORIZED PERSON’S SIGNATURE 14 DATE OF CURRENT ILLNESS 17 NAME OF REFERRING PHYSICIAN 21 DIAGNOSIS(ES) 24 a DATE(S) OF SERVICE 24 b PLACE OF SERVICE 24 d PROCEDURES, SERVICES, SUPPLIES USING CORRECT CPT, HCPCS AND MODIFIERS 24 e DIAGNOSIS CODE POINTER RELATED FROM BLOCK 21 24 f $ CHARGES 24 g DAYS OR UNITS OF SERVICE 24 j NPI NUMBER OF THE RENDERING PROVIDER 25 FEDERAL TAX ID NUMBER 26 PATIENT’S ACCOUNT NUMBER (OPTIONAL) 28 TOTAL CHARGE 31 SIGNATURE OF PHYSICIAN/SUPPLIER, INCLUDING DEGREES/CREDENTIALS 32 NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED 32 a NPI NUMBER OF THE SERVICE FACILITY 33 PHYSICIAN/SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE AND PHONE NUMBER 33 a NPI NUMBER OF THE BILLING PROVIDER

https://www.advanticabenefits.com/PDFs/AdvanticaBenefits/DocManagement/CMS1500fo9_49606_09_02_2016.pdf



The following fields are required when applicable:

BLOCK DESCRIPTION 9 OTHER SUBSCRIBER’S NAME 9 a OTHER SUBSCRIBER’S POLICY OR GROUP NUMBER 9 b OTHER SUBSCRIBER’S BIRTH DATE AND SEX 9 c EMPLOYER’S NAME OR SCHOOL NAME FOR OTHER PLAN 9 d INSURANCE PLAN/PROGRAM NAME FOR OTHER PLAN 15 DATE IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 18 DATE OF HOSPITALIZATION RELATED TO CURRENT SERVICES

Please note that below boxes are correct before submitting the claim: Box 3 Patient’s birth date and sex - verify that the birth date is correct Box 11 Subscriber’s policy group number – enter group number Box 11c Subscriber’s plan name – enter the name of the vision employer group name Box 12 Patient or authorized person’s signature – signature, or “signature on file” and date signed Box 13 Subscriber’s or authorized person’s signature – needs a signature or note “signature on file” Box 31 Signature of physician/date of signature/supplier, including degrees/credentials – needs a

signature and date signed Box 32 Name and address of facility where services rendered – need the complete address Box 33 Physician’s/supplier’s billing name, address, zip code and phone number – the address in box

33 must be the correct one for the tax ID number listed in box 25

NOTE: A reference number is not required in order to submit claims to Advantica. If your system requires a reference number you may enter the date in which you verified the member’s eligibility. This verification does not guarantee payment of claims submitted. The member must also be eligible at the time of service. NPI Numbers The provider’s NPI number should be included on the CMS Form 1500: • Box 24j – NPI number of the rendering provider. (Note: The rendering provider must be in-network) • Box 32a – NPI number of the service facility • Box 33a – NPI number of the billing provider

See pages 15-16 for Required Data Elements to complete a CMS 1500 form.

NOTE: Claims must be submitted with the Subscriber’s ID number exactly as it appears on the membership card, NOT the member’s social security number.



Submitting Claims Online Log on to www.advanticabenefits.com. Click on the Providers tab on the website navigation toolbar and

then Provider Login. Click here to access the portal directly or visit: https://www.advanticabenefits.com/Providers/Login

Prompts will appear, requesting a username and password. Once logged in, use the toolbar located on the left side of the webpage to navigate the website. To submit claims, simply click on the Online Claim Submission button found on the toolbar. Please ensure you are using the latest versions of Internet Explorer, or Chrome only. Firefox is not compatible at this moment.

Submit a Claim Begin by entering the date of service.

Locating a Member The second step in claim submission is locating the member. Provider can search for a member either by

entering Subscriber ID or Alt ID and then click Get Subscriber/Member. Another method is to enter last name, first name and date of birth of the subscriber only and then click Get Subscriber/Member. Once the subscriber is found, the rest of the below field will be auto-populated. Then, check the Signature box to sign electronically and click Next button.



http://www.advanticabenefits.com/Providers/Login





Selecting the member being treated From the drop-down, select the appropriate member. Once selected, all fields will be auto-populated and

click Next button.

Selecting Provider From the drop-down, select the appropriate provider along with service location. Once selected, all the

fields will be auto-populated and click Next button. (If you encounter an error after selecting the Provider, please contact Customer Service at 866-425-2323.)

Exam/Treatment Please proceed to Exam/Treatment tab to enter the services performed by the provider. Enter the

Diagnosis Code. Enter the Serv. Date From and the Serv. Date To. Complete the Procedure Code for the rendered services, using the approved CPT codes, see pages 21-24. The POS box is used to denote the place of services rendered, 11 is automatically filled in for provider’s

office.



Frames are billed as one unit with no modifier. Lens upgrades (high index, progressive, photochromic, UV, tint, etc.) are billed on one line with two units. *IMPORTANT NOTE ON BILLING FOR LENSES: When billing for lenses, the correct number of UNITS must be identified on the claim form. If no units are listed, only ONE lens will be paid. Please enter 1 unit for exam and frame procedure codes, and enter 2 units for lenses or contact lenses.

Enter the provider’s Usual and Customary charges before taxes. The description will be auto-populated. No modifiers are required The Diag Ptr box is used to reference the diagnosis code for each line of service. For example, if the

diagnosis for the exam is myopia you would enter H52.3 into the Diagnosis Code box number 1, and then use the Diag Ptr 1 to reference that diagnosis on the service line. (If no diagnosis pointer entered, the claim will not pay for that particular procedure code).

After filling out all necessary service lines, check Agree on behalf of the Member and the Provider and then click on the “Submit Claim” button to submit the claim for review.

The next screen will be for review. You must click on the “Submit Claim” button at the bottom of the

screen for claim to be processed.



Coordination of Benefits Advantica coordinates benefits with other plans the member may have. Generally, the following rules apply when determining whether Advantica is the primary or secondary carrier: Non-Dependent/Dependent - The plan that covers the member as a subscriber is primary over a plan

which covers the member as a dependent. Dependent Children - For a dependent Child, the Plan of the parent whose birthday occurs first in the

calendar year is primary. Unless there is a court order or divorce decree, in which case the plan of the parent who has responsibility for providing coverage is primary.

A copy of the primary carrier’s Explanation of Benefits (EOB) should be included with the claim when it has been determined that Advantica is the secondary payer for the patient. If Advantica receives a claim without the primary carrier’s EOB included it will request a copy of the primary payer’s explanation of benefits in order to adjudicate the claim.

Benefit Reinstatement Form Please complete the Advantica Vision Benefit Reinstatement Request Form when a member has received

a refund for materials or services purchased with their benefits. This form will allow a member’s benefits to be reinstated. This form is available by visiting the Advantica website at www.advanticabenefits.com, click the PROVIDERS tab, and scroll to the FORMS.

Fax completed form to: (314) 849-4830 or (800) 501-8432 Email completed form to: [email protected]

Claims Timely Filing Limitation A provider must submit a claim within ninety (90) days from the date of service, unless a longer time limit is provided for by applicable law. Failure to submit a claim within the filing limit will result in the claim being denied, and the provider may not bill the member for any covered services included on the claim.

Diagnosis Codes

ICD10 CODE DESCRIPTION H52.32 ANISEIKONIA H52.31 ANISOMETROPIA H27.03 APHAKIA, BILATERAL H27.02 APHAKIA, LEFT EYE H27.01 APHAKIA, RIGHT EYE H27.00 APHAKIA, UNSPECIFIED EYE H51.11 CONVERGENCE INSUFFICIENCY H53.11 DAY BLINDNESS H44.23 DEGENERATIVE MYOPIA, BILATERAL H44.22 DEGENERATIVE MYOPIA, LEFT EYE

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ICD10 CODE DESCRIPTION H44.21 DEGENERATIVE MYOPIA, RIGHT EYE H44.20 DEGENERATIVE MYOPIA, UNSPECIFIED EYE Z01.01 ENCOUNTER FOR EXAM OF EYES AND VISION W ABNORMAL FINDINGS Z01.00 ENCOUNTER FOR EXAM OF EYES AND VISION W/O ABNORMAL FINDINGS Z83.518 FAMILY HISTORY OF OTHER SPECIFIED EYE DISORDER H53.71 GLARE SENSITIVITY R51 HEADACHE H52.03 HYPERMETROPIA, BILATERAL H52.02 HYPERMETROPIA, LEFT EYE H52.01 HYPERMETROPIA, RIGHT EYE H52.00 HYPERMETROPIA, UNSPECIFIED EYE H53.72 IMPAIRED CONTRAST SENSITIVITY H52.513 INTERNAL OPHTHALMOPLEGIA (COMPLETE) (TOTAL), BILATERAL H52.512 INTERNAL OPHTHALMOPLEGIA (COMPLETE) (TOTAL), LEFT EYE H52.511 INTERNAL OPHTHALMOPLEGIA (COMPLETE) (TOTAL), RIGHT EYE H52.519 INTERNAL OPHTHALMOPLEGIA (COMPLETE) (TOTAL), UNSPECIFIED EYE H52.213 IRREGULAR ASTIGMATISM, BILATERAL H52.212 IRREGULAR ASTIGMATISM, LEFT EYE H52.211 IRREGULAR ASTIGMATISM, RIGHT EYE H52.219 IRREGULAR ASTIGMATISM, UNSPECIFIED EYE H52.13 MYOPIA, BILATERAL H52.12 MYOPIA, LEFT EYE H52.11 MYOPIA, RIGHT EYE H52.10 MYOPIA, UNSPECIFIED EYE H52.6 OTHER DISORDERS OF REFRACTION H52.6 OTHER DISORDERS OF REFRACTION H53.8 OTHER VISUAL DISTURBANCES H52.523 PARESIS OF ACCOMMODATION, BILATERAL H52.522 PARESIS OF ACCOMMODATION, LEFT EYE H52.521 PARESIS OF ACCOMMODATION, RIGHT EYE H52.529 PARESIS OF ACCOMMODATION, UNSPECIFIED EYE Z71.1 PERSON WITH FEARED HEALTH COMPLAINT IN WHOM NO DIAGNOSIS IS MADE H52.4 PRESBYOPIA Z96.1 PRESENCE OF INTRAOCULAR LENS H53.023 REFRACTIVE AMBLYOPIA, BILATERAL H53.022 REFRACTIVE AMBLYOPIA, LEFT EYE H53.021 REFRACTIVE AMBLYOPIA, RIGHT EYE H53.029 REFRACTIVE AMBLYOPIA, UNSPECIFIED EYE H52.223 REGULAR ASTIGMATISM, BILATERAL H52.222 REGULAR ASTIGMATISM, LEFT EYE H52.221 REGULAR ASTIGMATISM, RIGHT EYE H52.229 REGULAR ASTIGMATISM, UNSPECIFIED EYE H52.533 SPASM OF ACCOMMODATION, BILATERAL H52.532 SPASM OF ACCOMMODATION, LEFT EYE



ICD10 CODE DESCRIPTION H52.531 SPASM OF ACCOMMODATION, RIGHT EYE H52.539 SPASM OF ACCOMMODATION, UNSPECIFIED EYE H52.203 UNSPECIFIED ASTIGMATISM, BILATERAL H52.202 UNSPECIFIED ASTIGMATISM, LEFT EYE H52.201 UNSPECIFIED ASTIGMATISM, RIGHT EYE H52.209 UNSPECIFIED ASTIGMATISM, UNSPECIFIED EYE H52.7 UNSPECIFIED DISORDER OF REFRACTION H53.10 UNSPECIFIED SUBJECTIVE VISUAL DISTURBANCES H53.9 UNSPECIFIED VISUAL DISTURBANCE G44.1 VASCULAR HEADACHE, NOT ELSEWHERE CLASSIFIED H53.143 VISUAL DISCOMFORT, BILATERAL H53.142 VISUAL DISCOMFORT, LEFT EYE H53.141 VISUAL DISCOMFORT, RIGHT EYE H53.149 VISUAL DISCOMFORT, UNSPECIFIED

CPT Codes Below is the list of appropriate CPT codes to be used when completing a claim. Using these codes will expedite the processing of your claims upon initial receipt. Note: Not all plans include all services and materials listed below. Provider is responsible for verifying coverage.

CPT DESCRIPTION EYE EXAM 92002 OPHTH MEDICAL EXAM & EVALUATIOIN INTERMEDIATE NEW PATIENT 92004 OPHTH MEDICAL EXAM & EVALUATIOIN COMPREHENSIVE NEW PATIENT 1/> VISIT 92012 OPHTH MEDICAL EXAM & EVALUATIOIN INTERMEDIATE ESTABLISHED PATIENT 92014 OPHTH MEDICAL EXAM & EVALUATIOIN COMPREHENSIVE ESTABLISHED PATIENT 1/> VISIT 92015 DETERMINATION REFRACTIVE STATE S0620 ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; NEW PATIENT S0621 ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; ESTABLISHED PATIENT CONTACT LENS FITTING 92310 PRESCRIPTION & FITTING OF CONTACT LENS WITH MEDICAL SUPERVISION; CORNEAL LENS, BOTH EYES, EXCEPT

S0592 COMPREHENSIVE CONTACT LENS EVALUATION CONTACT LENS MATERIAL S0500 DISPOSABLE CONTACT LENS S0512 DAILY WEAR SPECIALTY CONTACT LENS S0514 COLOR CONTACT LENS V2500 CONTACT LENS, PMMA, SPHERICAL V2501 CONTACT LENS, PMMA, TORIC OR PRISM BALLAST V2502 CONTACT LENS, PMMA, BIFOCAL V2503 CONTACT LENS, PMMA, COLOR VISION DEFICIENCY V2510 CONTACT LENS, GAS PERMEABLE, SPHERICAL V2511 CONTACT LENS, GAS PERMEABLE, TORIC, PRISM BALLAST V2512 CONTACT LENS, GAS PERMEABLE, BIFOCAL



CPT DESCRIPTION CONTACT LENS MATERIAL V2513 CONTACT LENS, GAS PERMEABLE, EXTENDED WEAR V2520 CONTACT LENS, HYDROPHILIC, SPHERICAL V2521 CONTACT LENS, HYDROPHILIC, TORIC, OR PRISM BALLAST V2522 CONTACT LENS, HYDROPHILIC, BIFOCAL V2523 CONTACT LENS, HYDROPHILIC, EXTENDED WEAR V2530 CONTACT LENS, SCLERAL, GAS IMPERMEABLE V2531 CONTACT LENS, SCLERAL, GAS PERMEABLE V2599 CONTACT LENS, OTHER TYPE FRAMES V2020 FRAMES, PURCHASES V2025 DELUX FRAME SINGLE VISION LENSES V2100 SPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D V2101 SPHERE, SINGLE VISION, PLUS OR MINUS 4.12D TO PLUS OR MINUS 7.00D V2102 SPHERE, SINGLE VISION, PLUS OR MINUS 7.12D TO PLUS OR MINUS 20.00D V2103 SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00D CYLINDER V2104 SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12-4.00D CYLINDER V2105 SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25-6.00D CYLINDER V2106 SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER V2107 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, .12-2.00D CYLINDER V2108 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 2.12-4.00D CYLINDER V2109 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 4.25-6.00D CYLINDER V2110 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25-7.00D SPHERE, OVER 6.00D CYLINDER V2111 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, .25-2.25D CYLINDER V2112 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, 2.25-4.00D CYLINDER V2113 SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, 4.25-6.00D CYLINDER V2114 SPHEROCYLINDER, SINGLE VISION, SPHERE OVER PLUS OR MINUS 12.00D V2115 LENTICULAR, (MYODISC) , SINGLE VISION V2118 ANISEIKONIC LENSES, SINGLE VISION V2121 LENTICULAR LENSES , SINGLE V2199 NOT OTHERWISE CLASSIFIED, SINGLE VISION LENSES BIFOCAL LENSES V2200 SPHERE, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D V2201 SPHERE, BIFOCAL, PLUS OR MINUS 4.12D TO PLUS OR MINUS 7.00D V2202 SPHERE, BIFOCAL, PLUS OR MINUS 7.12D TO PLUS OR MINUS 20.00D V2203 SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00D CYLINDER V2204 SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12-4.00D CYLINDER V2205 SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25-6.00D CYLINDER V2206 SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER V2207 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE,.12-2.00D CYLINDER V2208 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 2.12-4.00D CYLINDER V2209 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 4.25-6.00D CYLINDER V2210 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, OVER 6.00D CYLINDER



CPT DESCRIPTION BIFOCAL LENSES V2211 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, .25-2.25D CYLINDER V2212 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, 2.25-4.00D CYLINDER V2213 SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, 4.25-6.00D CYLINDER V2214 SPHEROCYLINDER, BIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D V2215 LENTICULAR (MYODISC) , BIFOCAL V2218 ANISEIKONIC , BIFOCAL V2219 BIFOCAL SEG WIDTH OVER 28 MM V2220 BIFOCAL ADD OVER 3.25D V2221 LENTICULAR LENSES , BIFOCAL V2299 SPECIALTY BIFOCAL (BY REPORT) TRIFOCAL LENSES V2300 SPHERE, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D V2301 SPHERE, TRIFOCAL, PLUS OR MINUS 4.12D TO PLUS OR MINUS 7.00D V2302 SPHERE, TRIFOCAL, PLUS OR MINUS 7.12D TO PLUS OR MINUS 20.00D V2303 SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00D CYLINDER V2304 SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.25-4.00D CYLINDER V2305 SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25-6.00D CYLINDER V2306 SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D CYLINDER V2307 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, .12-2.00D CYLINDER V2308 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 2.12-4.00D CYLINDER V2309 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, 4.25-6.00D CYLINDER V2310 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D SPHERE, OVER 6.00D CYLINDER V2311 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, .25-2.25D CYLINDER V2312 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, 2.25-4.00D CYLINDER V2313 SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25D TO PLUS OR MINUS 12.00D SPHERE, 4.25-6.00D CYLINDER V2314 SPHEROCYLINDER, TRIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D V2315 LENTICULAR, (MYODISC) , TRIFOCAL V2318 ANISEIKONIC LENSES, TRIFOCAL V2319 TRIFOCAL SEG WIDTH OVER 28 MM V2320 TRIFOCAL ADD OVER 3.25D V2321 LENTICULAR LENSES , TRIFOCAL V2399 SPECIALTY TRIFOCAL (BY REPORT) PROGRESSIVE LENSES V2781 STANDARD PROGRESSIVE LENSES ADD-ON & UPGRADES V2744 TINT, PHOTOCHROMATIC V2745 ADDITION TO LENSES; TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, EXCLUDES PHOTOCHROMATIC, ANY LENS

MATERIAL V2750 STANDARD ANTI-REFLECTIVE COATING V2755 UV COATING V2760 SCRATCH RESISTANT COATING V2761 MIRROR COATING, ANY TYPE, SOLID, GRADIENT OR EQUAL, ANY LENS MATERIAL V2762 POLARIZATION, ANY LENS MATERIAL



CPT DESCRIPTION ADD-ON & UPGRADES V2784 LENS, POLYCARBONATE OR EQUAL, ANY INDEX SAFETY EYEWEAR S0516 SAFETY EYEGLASS FRAMES S0510 NON-PRESCRIPTION LENSES (SAFETY ONLY) S0504 SINGLE VISION PRESCRIPTION LENSES (SAFETY ONLY) S0506 BIFOCAL VISION PRESCRIPTION LENSES (SAFETY ONLY) S0508 TRIFOCAL VISION PRESCRIPTION LENSES (SAFETY ONLY)

Provider Appeals As a participating provider you have the right to file an appeal for a claim denial. If your claim is wholly or partially denied, you have 180 days to file an appeal from the date of your remittance advice. A provider has the right to a first and second level appeal. Provider appeal rights will be exhausted after the second level appeal. An appeal must be filed in writing stating why you believe the claim should be paid. Please include the patient’s name, DOB, ID number, date of service, claim number and any documentation to help support your claim appeal. Appeals for Timely Filing: If you are appealing a denial for ‘failure to timely file’ the supporting documentation should include proof of timely filing. For claims submitted electronically, Advantica will accept an electronic data interchange (EDI) acceptance report as proof of timely filing. For paper claims submissions, Advantica will accept a detailed screen shot from your software that includes the patient name, date of service and the date the claim was submitted as proof of timely filing. You can submit your appeal in writing by mail or by secure email at the addresses below.

Mail: Advantica

Attn: Appeals Department P.O. Box 8510 St. Louis, MO 63126

Secured Email: [email protected]

Member Appeals and Grievances Our Member’s have the right to appeal a denial of benefits by Advantica or submit a grievance regarding treatment they received from a network provider. As a participating provider you are required to assist in the investigation and resolution of any Member appeal or grievance. Such assistance may include, but is not limited to: speaking with an Advantica Representative regarding the appeal or grievance, providing copies of the member’s treatment records, or providing your records for review.




Fraud Waste and Abuse Advantica is committed to detecting, reporting and preventing potential Fraud, Waste and Abuse (FWA). Fraud, Waste and Abuse are defined as: Fraud: Intentional deception or misrepresentation made by a person with the knowledge that the

deception could result in some unauthorized benefits to himself or some other person. It includes any act that constitutes fraud under federal or state law.

Waste: Over-utilization of services or other practices that, directly or indirectly result in unnecessary costs to a health care benefit program.

Abuse: Requesting payment for items or services when there is no legal entitlement to that payment. Unlike fraud, the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.

Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost to the program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care are considered Fraud, Waste and Abuse. Such practices may lead Advantica to recover benefit payment on behalf of the member. Examples included: Misrepresentation of the dates of service, services performed or fees charged on the claim submitted

including: - Adjusting the date of service to capture unused benefit payments or avoid denial for timely filing - Using a participating providers NPI to submit claims when care was actually provided by a non-

participating provider to have the services paid as “in-network” - Unbundling or up-coding

Over-utilization of services or the misuse of resources. Such as routinely billing for additional treatments which are not medically necessary.

Routine waiver of applicable co-payments and deductibles. Cooperating /aiding a patient to commit fraud using another enrolled person’s identity/eligibility. If a

Provider suspects a member of identity fraud, this should be reported to Advantica’s Provider Relations.

If you have a reason to believe Fraud, Waste or Abuse (FWA) has been committed, please contact us immediately because together we can make a difference. You can report information anonymously and confidentially 24 hours a day, 7 days a week. Contact options are listed below:

Mail: Advantica Attention: Quality Management Department 12399 Gravois Road, Second Floor St. Louis, MO 63127 Phone: (866) 425-2323 Email: [email protected]


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