About PVCS | The Plan | Contact Us | F.A.Q. | Find a Doctor! | Provider Login

VisionAdvantage Plan Handbook Effective 02/01/2002 Quick Links Plan Overview Eligibility Services Covered Wholesale Cost Services Not Covered Claim Submission Claim Reimbursement Marketing PLAN OVERVIEW The PVCS VisionAdvantage Plan is very different from other vision care plans. From the service provider's viewpoint unique aspects of the PVCS VisionAdvantage Plan include the following:   Verification of plan member eligibility is quick, easy, and accomplished by real people on the other end of the line. Very few limits or restrictions on the conduct of your Optometric practice. PVCS pays for provider services while the patient pays for eyewear materials (frames, lenses, etc). Materials provided to covered plan members are sold at "wholesale cost" as defined by the plan. There is no annual limit to the number of patient encounters or the quantity of eyewear materials offered under the plan covenants. Service claims are easy to submit and claim payments are prompt. Provider reimbursement statement can be quickly and easily reconciled to office claims records. ELIGIBILITY Call PVCS (1-888-357-6912) or (locally, 357-6912) to verify patient eligibility. To ensure a timely response, please have:   the correct spelling of the Enrollee’s (Sponsor’s) name, patient’s name (if different), and the Enrollee’s employer. SERVICES COVERED   Office calls for general vision problems or questions when needed. Eye Exams – when needed -- either intermediate or comprehensive in scope. Eyeglass fittings – any and all fittings for eyeglasses are to be provided. You are paid a service fee for each pair you dispense. Simply write the number of pairs you supplied for each patient on the claim form in the appropriate column. For frame only or single vision lenses only, check the SV RX column. For multifocal lenses only, check the MF RX column. Materials (lenses, frames, and options) are to be provided at “wholesale cost” as defined below. Contact lens fittings – original fittings (New CL Fit) and complete refittings should collect a $50.00 service fee deductible (copayment) in addition to the material’s wholesale cost. A contact lens refitting (CL Ref) involves a major change in the wearer’s contact lens prescription or fit, such as a change from daily wear to disposable. Contact lens replacements or routine power changes should not charge the service fee, but should collect the wholesale cost of the materials as defined below. Contact lens visits – do not file separate claims for contact lens progress visits or check-ups relative to an original fit or refit for which you have previously billed. Those billings are considered global for the first 6 months after a fitting up to the time for the next scheduled exam when you may again bill for the appropriate level of service. Eyeglasses repairs and adjustments – no reimbursement for these services. You may charge for any material costs incurred. WHOLESALE COST   The “wholesale cost” for frames is defined as:   1) the current catalog listed wholesale price in Frames magazine for eyeglass frames, 2) plus applicable shipping costs and sales tax rounded up to the nearest $5.00 increment. The "wholesale cost" for eyeglass lenses is defined as:   1. the local or customary wholesale laboratory posted rate sheet for eyeglass lenses and options, 2. plus applicable shipping costs and sales tax rounded up to the nearest $5.00 increment. The “wholesale cost” for contact lenses is defined as:   1) the manufacturer's or distributor’s published wholesale charge for any materials costs incurred, price per-lens or per-box, 2) plus applicable shipping costs and sales tax rounded up to the nearest $5.00 increment. (For example, by this definition, one box of six ACUVUE lenses would have a wholesale cost of $20.00). These definitions of “wholesale cost” may leave a small buffer. Any volume buying, group, or prompt pay discounts belong to the doctor. Prudent management of materials purchases will work to your benefit. PVCS provides you with a standard wholesale price listing for lenses and some options. However, we recommend you make or review your own wholesale price list using your wholesaler’s information to insure you are covering your costs. Offices using their own laboratories are considered by PVCS as operating two businesses. In this case, your Laboratory is acting as a Wholesaler to your practice. We recognize you have laboratory operating and inventory costs that must be accounted for in calculating your particular practice’s “wholesale cost”. We offer the use of our published “PVCS Wholesale Price List” to assist you in calculating the appropriate wholesale price to be paid by the patient. Some doctors may be uncomfortable using the descriptor “wholesale cost” when discussing charges with the patient. In this case, we offer the use of “co-payment” as an accurate, widely recognized descriptor of the material charges. Please understand that patients are aware you “mark-up” materials and that this has not been a problem. However, if admitting mark-ups is a sore spot, please go ahead and use the “co-payment” terminology when dealing with your patient. SERVICES NOT COVERED   What is NOT covered under this plan? Services such as:   Vision therapy Laser treatments, refractive surgery, or other forms of ophthalmic surgery Photography Corneal Topography Orthokeratology Other non-routine procedures Medical eye care (unless purchased as an option) Medications other than those used in the exam Luxury frames (any frame costing over $100 wholesale) Non-prescription eyewear (sun or safety glasses) New technology not considered routine at the inception of a contract What do you charge for services NOT covered under this plan? Your usual and customary fee, paid by the patient. CLAIM SUBMISSION   How do you file a claim for services covered under this plan? PVCS’s unique claim form allows you to file up to eight (8) claims on a single form in only a few seconds of your valuable time. Please photocopy your master form and use copies to file your claim. Fill-in the standard boxes of Doctor’s Name, Fed ID #, City, State, Date submitted, and Doctor’s Phone Number as shown on the sample below: Sample PVCS Claim Form Showing Typical Entries Then for each patient, fill-in specific information concerning the:   Name of the employee (enrollee/sponsor) covered by the plan, Employee’s (enrollee/sponsor) Social Security Number (SSN), Patient’s name if different than that of the enrollee Name of the Employer (firm/agency/organization sponsoring the Plan), and The date the patient was seen. If a patient is seen more than once in a given month, fill-out another patient record (row) for each additional date. To complete the patient record, fill-in the appropriate service columns:   Place a check mark in the space for each service performed. When dispensing multiple RX’s, simply write in the number of pairs dispensed. Check only one of the office visit/exam related columns. Check only one of the four possible contact lens columns.   Use check marks in the first three columns (New CL Fit, CL Ref, and Type CL Repl Non-Disp). If you dispense disposable contact lenses, indicate in the Type CL Repl Disposable column the number f months supply dispensed (example, 3 or 6). If a single check mark appears in this column, we will assume you issued a 3-month supply. Simply replacing or updating contact lenses for a patient does not constitute a contact lens refitting. A CL Refitting (CL Ref) involves a major change in the wearer’s contact lens prescription or fit. What about filing a claim for unusual circumstances (doesn’t fit the standard categories)? In these cases, simply check the miscellaneous (MSC) column. Then, on and attached sheet or on the back of the original claim sheet, put the patient’s name and a brief explanation of the case plus appropriate supporting data (For Example: John Doe, Keratoconus procedure -- include the amount of additional work performed). The PVCS Medical Director will review the claim, possibly talk with the doctor, and assign a point value to the services provided. This simple format is designed to enable the Plan Administrator to execute the shortest possible turn-around time for payment. When do you submit claim forms? Monthly -- so as to arrive at PVCS no later than 4:00 PM of the 5th calendar day of the month for the previous month’s work. If the 5th of the month falls on a weekend or legal holiday, the deadline shall be 4:00 PM the next business day. All claims submitted after this time will automatically be added to the next month’s claims. Claims must be submitted to PVCS no later than 90 days from date of service to be considered a valid claim for reimbursement. Any claim received after the 90 days valid claims period will not be reimbursed. How do you submit claim forms? Claims may be submitted at anytime during the claim period. For example, some of our panel members fax us claims on a weekly basis. By Mail: You may want to use priority or express mails to ensure meeting the deadline or you may choose to cut-off your month’s claims before the last day of the month to be sure they are in on time. By Facsimile (Fax): 1-580-357-6919 By E-mail: pvcs@sirinet.net Send claim form as an attachment or enclosure to your e-mail transmission in a format compatible with Microsoft Word 6.0. CLAIM REIMBURSEMENT   When and how will you be paid? Checks are printed and mailed to individual providers by the 15th of each month (five working days or less after claim cut-off is the target). Our simple administrative plan makes this possible. How much will you be paid? PVCS uses a unique modified capitation method based on assigned service points and a targeted service point value to determine your fee.   Service Points: Each professional service you provide is assigned a service point value (numerical value). Target Dollar Value: Annually, PVCS establishes a target dollar value for each service point. This value, along with computed service points, is prominently displayed on the provider's reimbursement statement. Service Reimbursement Table (Reflecting the current Target Dollar Value of $10.00) Professional Service Provided Claim Form Column Service Points Service Reimbursement Office Call Off Call 2 ea. $ 20.00 Intermediate Exam Int Exam 4 ea. $ 40.00 Comprehensive Exam Comp Exam 6 ea. $ 60.00         Single vision glasses dispensing SV RX 3 ea. $ 30.00 Multifocal glasses dispensing MF RX 5 ea. $ 50.00         Original contact lens fitting New CL Fit 6 ea. $ 60.00 Contact lens refitting CL Ref 4 ea. $ 40.00 Contact lens replacement – Non-Disposable Applies to daily or extended wear, toric or gas permeable, issued as one or two lenses Type CL Repl Non-Disp 2 ea. $ 20.00 Contact Lens replacement – Disposable Per 3-month supply Type CL Repl Disposable (# Months) 1 ea $10.00 For example, using the above table, a doctor providing a comprehensive exam (6 Svc Pts) and fitting the patient for new contact lenses (6 Svc Pts) for a total of 12 Svc Pts claimed, is targeted to receive $120.00 as claim payment from PVCS. The actual value for any given service point is calculated on the basis of monthly revenue divided by monthly claims as addressed in the Optometrist's contract. PVCS HAS PAID ITS TARGETED VALUE EVERY MONTH SINCE THIS SYSTEM BEGAN! A well-managed practice should find these figures quite acceptable under today’s operating conditions. What do you receive in addition to a check? Each claim payment is accompanied by a Provider's Reimbursement Statement, an example of which is shown below. The reimbursement statement provides both the target and actual service point value for the claim period and consolidated figures for number of plan member encounters, total service points, and total dollar reimbursement (the same value as on the reimbursement check). Sample PVCS Provider Reimbursement Statement The remaining information is intended to assist in reconciling the reimbursement with your copy of the claims and individual patient records. You will find each claim submitted during the period listed by ascending date. In addition to the date, you will find the patient's name, services claimed, and service points assigned.   No materials are shown on this statement. Remember, the plan member pays wholesale price (as defined by the plan) for all materials either at the time of purchase or through provider billing. Note that, in the above sample, plan member John Smith was seen by the doctor twice during the claim period and both claims were reimbursed under the VisionAdvantage Plan. The service reimbursement for an individual patient can easily be computed by multiplying total individual service points by the value of the "actual payment per service point this period" (found as part of the notes in the upper right hand corner of the statement). MARKETING   PVCS is marketed primarily through independent brokers who specialize in employee benefits for both the private and public sector. PVCS also subcontracts Medicaid and Medicare vision care through HMOs. Additionally, PVCS does some limited direct marketing to larger groups. If you have an employer group you would like to add to PVCS, please have their representative contact us or let us know whom to contact in that organization.   Back to the top

PVCS - Primary Vision Care Services 2518 W Gore Blvd - Suite C, Lawton, OK 73505-6315 Phone: 580-357-6912 | Fax: 580-357-6919 | Toll Free: 888-357-6912 Terms of Service  |  Privacy Policy