Medically Necessary C/L claim

[a1vo]

I'm about to have a customer to come in to purchase C/L from me, who, in the past, always had VSP OD get "medically necessary C/L" coverage because of her high anisometropia.

As an independent non-VSP optician, what should I do to get her the same medical necessary C/L coverage?

What are the insurance company's qualifications of medical necessary C/L? Is there a "form letter to insurance company" for such claim my fellow ECP willing to share with the forum? Will the insurance consider my signature (as licensed optician) on the form letter as "qualified" medical personnel?

Thank you all in advance who willing to share the experience.

[cocoisland58]

The correct diagnosis is what it takes. If I were you I would call the examining doctor and get one.

[a1vo]

and was told I, as a licensed contact lens dispenser, can sign the required letter accompany with claim form and other needed information and my patient can be reimbursed for the medical necessary C/L (if qualify). yaaaaa:cheers:

[cocoisland58]

and was told I, as a licensed contact lens dispenser, can sign the required letter accompany with claim form and other needed information and my patient can be reimbursed for the medical necessary C/L (if qualify). yaaaaa:cheers:

I'll say one thing for VSP they are always very helpful and personable.

[a1vo]

I'll say one thing for VSP they are always very helpful and personable.

not necessarily true if you are an OUT-OF-NETWORK provider

[npdr]

An out of network provider, whether they be optometrist or ophthalmologist
or optician, will always get a reimbursement for part of the out-of-pocket cost of the contact lenses.

For example, let's suppose a network doctor does a keratconus fit. The usual charge is $800. The network will reimburse the doctor for 80% of the cost of what the average optometrist will charge. I think it is community-based. The network provider accepts this in kind and cannot 'balance bill' the patient except for any deductibles or other overages.

An out-of-network provider puts the weight of the reimbursement onto the patient. The patient submits a super bill requesting a medically n ecessary contact lens fit . The prescribing (!!!) doctor must provide the medical justification of the fit. THe dispenser only has to provide the invoice that the bill pays. VSP will usually reimburse the patient some portion of that the total bill (but less than what a network doctor would charge.

[HarryChiling]

and was told I, as a licensed contact lens dispenser, can sign the required letter accompany with claim form and other needed information and my patient can be reimbursed for the medical necessary C/L (if qualify). yaaaaa:cheers:

The other needed information is a letter from the doctor stateing the reason as to why the CL's are medically necessary. If you call the doctors office and request the letter most will oblige. No matter what they tell you over the phone, you are not qualified to make a diagnosis.