|FREQUENTLY ASKED QUESTIONS
( General | Materials | Claims)
- What is Envolve Benefit Options relationship with Georgia Medicaid and Peach State Health Plan?
Peach State Health Plan has contracted with Envolve Benefit Options to provide routine vision and limited medical care services to members of their health plan. As a vision care vendor, Envolve Benefit Options doesn’t have a direct contractual relationship with the State.
- Are Other Georgia Care Management Organizations (CMO) participating with Envolve Benefit Options?
No. Only Peach State Health Plan is participating with Envolve Benefit Options.
- When does Envolve Benefit Options Administration begin?
Envolve Benefit Options begins administration for Peach State Health Plan on 8/1/2007.
- Are there any significant differences between Avesis administration and Envolve Benefit Options administration?
Envolve Benefit Options has worked diligently to ensure a seamless transition for the Providers and Members.
- Who do I contact if I need help or have questions?
Please click here for a link to our main provider's page.
- What are the advantages of participating in the Georgia Medicaid program administered by Envolve Benefit Options?
1)Timely and accurate claims processing
2)Ease of administration (including but not limited to Internet, EDI and paper claim adjudication)
3)Ease of participation (no redundant paperwork)
4)Ability to dispense frames from three options (GCI, Essilor Frame Kit, or your own frame selection)
- If I decide to participate in the program, what should I do?
Please contact the Network Development Department at (800) 531-2818. You will be sent a Panel Participation Request form to capture the necessary information to begin the process of becoming a participating provider or you may download and submit a participation request form to toll-free fax number (800) 980-4002.
- If I add a provider to my practice, are they automatically participating with the program?
No, each provider must have his or her own Medicaid number and must be contracted and credentialed by Envolve Benefit Options prior to seeing a PSHP member. Please refer to FAQ #7 for instructions.
- How do I get credentialed by Envolve Benefit Options?
Upon receipt of your completed information (sent to you by Network Development), Envolve Benefit Options Credentialing Department will roster providers with The Council for Affordable Quality Healthcare’s (CAQH) Universal Credentialing Datasource to expedite our recruiting process. Envolve Benefit Options is the first eye care network management company to receive participation status with the CAQH Universal Credentialing Datasource program. What this means for our providers is that you finally have the opportunity to complete and submit a single, universal credentialing application to fulfill the credentialing requirements for many managed care payers. The Credentialing Process must be completed prior to providing services to Peach State Health Plan members.
- How do I verify a Peach State Health Plan- Georgia Medicaid Member’s eligibility?
You may use the Envolve Benefit Options secure website on a 24/7 basis. Or you may call Customer Relations at (866) 458-2139 to be assisted by a representative between the hours of 8 am and 7 pm Monday through Friday (EST).
- Am I contracted to provide non-routine eye care to patients covered by Envolve Benefit Options?
It depends on two (2) factors:
1. First you need to know what Envolve Benefit Options agreement with a specific health plan covers. If the agreement covers both routine vision and medical eye care then the answer is maybe.
2. If the answer to 1 is yes, then you would need to verify that your credentialing status with Envolve Benefit Options is for “full scope of practice”. Drs w/out DEA or CDS are not credentialed for full scope and as a result are eligible only for delivery of routine vision care to covered enrollees. If you aren’t sure what your status is, please contact Envolve Benefit Options Provider Relations.
Materials (Back to Top)
Is it necessary for me to sign up for one method of material (eyeglasses) fulfillment at a time?
No. Providers may use any one of the three options at any time. This affords greater flexibility when making fulfillment decisions.
- What are the frame dispensing options and requirements if I choose to use my own inventory or lab?
Provider must be able to dispense a selection of 35 frame styles (20 children’s, 5 unisex adult, 5 men’s, and 5 women’s) at no cost to the eligible Member. Frames must be ophthalmic quality backed with a minimum of 1 year manufacturer warranty. Frames under “A” dimension should not be oversized to exceed 56 mm and ‘B” dimension frames of less than 24mm.
- Can I distribute a discontinued frame to a Medicaid Member?
No. Discontinued frames may not be offered to avoid the inability to replace damaged or defective frames.
- Can members use the $40.00 “buy-up” allowance for purchase of contact lenses?
No, the $40.00 allowance may not be used to purchase contact lenses. However, the allowance may be used to purchase frames beyond the standard selection or for other options not covered by the Medicaid plan such as: A/R coating, polycarbonate lenses, or photochromatic tint. The Member is responsible for all charges for the eyewear over $40.00. Providers should ask the Member to sign “Acknowledgement of Financial Responsibility Form”, which signifies their understanding that they have a payment obligation on their glasses order.
- Can members choose frames outside of the Medicaid selection?
Yes, members may elect to “buy-up” and use their $40.00 frame allowance towards the cost of the frame. Providers should ask the member to sign a Peach State Acknowledgement of Financial Responsibility Form, which signifies their understanding that they have a payment obligation on their glasses order.
- What type of lens is the member eligible for at no cost to them?
Standard CR-39 lenses should be provided at no cost to the member.
- Can members add non-covered options to their eyeglasses?
Yes. Members may elect to add on non covered items such as cosmetic tints, anti-reflective coating, and progressive bi-focal lenses; however the member should be advised that they will be responsible for the additional cost and should sign an “Acknowledgement of Financial Responsibility Form”, which signifies their understanding that they have a payment obligation on their glasses order.
- Can I use the Georgia Correctional Industries (GCI) lab to place orders for non-standard frames, lenses, or add-ons?
No. The GCI agreement with Envolve Benefit Options does not cover upgraded frames or buy-ups.
- Which methods of fulfillment allow a dispensing fee?
Only the GCI option allows the dispensing fee. When you are using the GCI option for fulfillment, you should only bill the applicable dispensing code: 92340, 92341, or 92342 when you submit your claim to Envolve Benefit Options. Please indicate “GCI” in box 23 of the CMS-1500 claim form. GCI will send Envolve Benefit Options a bill directly for the cost of the materials.
- Where can I obtain information about Essilor?
Please click here to view PDF Document.
- For my GA Medicaid patients I typically use the GA Dept of Corrections (GCI) optical lab to supply and fabricate glasses; can I continue using this lab for Peach State Health Plan patients through Envolve Benefit Options?
Yes. Using the GCI lab is one of the three(3) options we you have for supply of glasses to Peach State patients. Just use the same GCI sample kit of frames. Be sure to fill out the lab orders on the Envolve Benefit Options GCI order form. If you need this form, click here. [see your Benefit Information Summary for the applicable claim submission codes]
- What if my Peach State patients request an upgraded, “nonstandard” frame and /or lenses; can I still use the GCI optical lab to make those glasses?
No. You should not send the lab order to GCI when a Patient chooses to purchase “non-covered” frames* or lenses. In this case, you have two(2) choices for fabrication of the glasses. You can(1) send the job to the local Essilor lab (e.g. Southern) or (2)make them in your own facility. [see your Benefit Information Summary for the applicable claim submission codes] * this also applies to patients who use their own frames
- I usually use the contracted Essilor lab to supply the materials and make the glasses for Peach State Patients; will I receive a bill for the lab charges or does Essilor bill Envolve Benefit Options directly? And, how does the billing work if I order non-standard materials?
All lab charges from the Essilor lab are billed to the provider’s individual account. The provider is responsible for paying their own lab bill. The provider then submits a claim to Envolve Benefit Options for materials (according to CPT) and is reimbursed according to the applicable fee schedule. This scenario applies to both covered, standard and for non-covered, upgraded lenses.
Claims (Back to Top)
- How are claims for services submitted?
Envolve Benefit Options accepts claims electronically through Emdeon (Web MD); via the secure Envolve Benefit Options website, or paper (CMS-1500 claim form) which can be mailed to:
Envolve Benefit Options
P.O. Box 7548
Rocky Mount, NC 27804
- My office files claims electronically. What is Envolve Benefit Options Payer ID?
Envolve Benefit Options Payer ID is 56190.
- How do I get signed up to enter claims through your website?
Envolve Benefit Options has an on-line claims entry application available through the secure website. In addition to claims entry, providers may download or print explanation of benefit reports, check claim status, and verify eligibility and/or benefits. You must have a login assigned by Envolve Benefit Options. Please download the Security Request Form, complete it, and fax it to (800) 980-4002.
- How long does it take for claims to be paid?
All clean claims are processed by Envolve Benefit Options within 15 business days of receipt.
- How long do I have to file a claim?
You have 90 days from the date of service to file a claim. We suggest that you follow up with Envolve Benefit Options if you have not received a disposition within 30 days.
- How do I get reimbursed for services rendered prior to August 1, 2007?
For dates of service prior to August first, your claim should be submitted to Avesis.
- What codes should I use to bill for a routine eye exam?
You should use the appropriate exam CPT code: 92002, 92012, 92004, or 92014. You must also use a valid routine exam code. The following codes are considered “routine”: 367.0, 367.1, 367.20, 367.21, 367.22, 367.31, 367.32, 367.4, 367.51, 367.52, 367.53, 367.8, and 367.9. When a routine exam is performed and no refractive error is found, please use V72.0.
- How should I bill an exam when a patient requests a routine exam (has no chief complaint), but an eye problem is discovered?
Regardless of final diagnosis, a patient who presents for an eye examination with no complaint must be reported as a routine eye examination (initial visit only) listing ICD-9 codes V72.0 or 367.0 through 367.9 as the primary diagnosis in box 21 and the diagnosis reference point in Box 24E of Form CMS-1500. Any medical diagnosis should be listed as secondary. The coverage of services rendered by an eye care provider is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. Therefore, if a patient presents to a provider’s office for a routine examination, and during the course of the examination a medical diagnosis is discovered, the examination is still reported as routine. This information is based on a Medicare determination, which can be found in the Medicare Carrier Manual, Part 3, under Coverage and Limitations 08-94 section 2323. CMS makes it very clear that coverage for ophthalmology exams is determined based on the "purpose for the exam" rather than the ultimate diagnosis of the patient's condition. Supporting documentation may be viewed here.
- What if I disagree with a claim determination or payment?
First, place a telephone call to the Envolve Benefit Options Provider Relations Department to see if the claim qualifies as an informal claim adjustment. If so, no further action on your part is necessary. The claim will be adjusted and you will be reimbursed on your next Provider EOB. If the claim does not qualify as an informal claim adjustment, you will be directed to send in a “Request for Claim Review” form. Envolve Benefit Options must receive this within 45 days of the date of the EOB. Envolve Benefit Options will send a written response within 30 days of receipt of the form. If you are still unhappy with the determination, you may file a Provider Complaint to Envolve Benefit Options. Your Provider Complaint must be filed within 30 days of your receiving the initial determination letter. You will be sent an acknowledgement letter within 10 business days of receipt of your request and Envolve Benefit Options will provide a written response within 30 days of receiving your letter of complaint.
- Are there any services that require prior notification to Envolve Benefit Options?
The only service that Envolve Benefit Options requires prior notification for is medically necessary contact lenses for conditions or reasons other than Aphakia, Keratoconus, and Bandage. You may download a Special Request form and fax it to the Medical Management Department, 252-451-2908. As a reminder, the Optometrist or Ophthalmologist must certify that the contact lenses are indicated due to a medical reason.
- Am I allowed to bill for a routine exam and a medical exam on the same day?
Typically no. When a patient presents for eye examination or E/M services, they may or may not have a chief complaint. If the chief (entering) complaint is for routine care then you would use the normal exam code (e.g. 92004 + 92015), regardless of incidental diagnoses you may otherwise find. If the patient presents with specific “medical” (non-routine) symptoms then you would bill for the 92XXX code or the applicable E/M code. In very rare circumstances you may feel it appropriate to use the routine exam code (e.g. 92XXX) and add the additional 99XXX code with the -25 modifier to distinguish it as a “significant, separately identifiable service”. The key word here is “significant”. An example might be a patient who presents for an “annual eye exam to update their glasses” and during your indirect exam find a retinal tear. You would then work them up for the retinal problem with applicable documentation and referral coordination.