Claims Filing Highlights - Vision

Important Note:

Effective January 1, 2022, HMSA has partnered with EyeMed for routine vision services for the following lines of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees.

Non-routine vision services remain under our medical benefit and will be processed as such.
For more information, please visit EyeMed at www.eyemedinfocus.com.

To expedite processing, please complete your claims carefully. Clear, accurate information is essential for HMSA to process your claims correctly and without delay. The following CMS 1500 claims filing highlights will help you prepare claims that can be processed quickly and accurately.

Ask your patient, each time he or she visits, if there has been a change in his or her medical coverage. Doing so will enable you to provide HMSA with a correct member ID number and reduce the number of claims that are returned to you for corrected membership information.

Both the provider's signature (or the signature of an authorized representative) and the correct HMSA provider number are needed to process the claim. If a signature stamp or electronic signature is used, it must be initialed by the provider or authorized agent. If either the provider's signature or HMSA provider number is missing or illegible, the claim may be returned to you.

Providers with more than one location or line of business should verify that they are billing under the correct provider number and that the provider number they use is active for the dates of service being billed.

Always use the most current code books available. HCPCS and ICD-9-CM are updated yearly - new codes are added and outdated codes are deleted. An ICD-9-CM diagnosis code is required to indicate why specific services were rendered. When selecting a diagnosis code, use the most specific diagnosis available - through the fifth position when appropriate. (Note: Do not add zeros after the decimal to artificially create five positions.) For ophthalmological exam billing examples and relationship between the benefit applied and diagnosis code billed on the claim, please review the information on the Provider Resource Center page – Ophthalmological Exam - With or Without Refraction.

When Motor Vehicle Insurance, Third Party Liability, or Workers' Compensation issues are involved, please check the appropriate "Yes" box in Block 10 of the CMS 1500 claim form and list an "E" diagnosis code (describing the place of injury) as the final diagnosis in Block 21. You do not need to include any other information about the accident on the claim form; HMSA will ask the member for details.

Be sure to verify the information entered on the claim form. A simple transposition error can delay the claim's processing or cause it to be processed incorrectly.

When a patient is referred to you for service, please be sure to enter the name of the referring provider (in last name, first name, middle initial format) in Block 17 of the CMS 1500 claim form. Do not include the referring provider's title (e.g., M.D.)

Conditional Blocks

HMSA regards some blocks of the CMS 1500 claim form as conditional; they do not need to be completed on all claims, but must be completed under certain circumstances. For detailed information about the correct completion of each block on the CMS 1500 claim form, we encourage you to refer to CMS 1500 Claim Form - General Instructions.

We frequently receive claims that contain incorrect information in Block 17, or do not contain needed information in this block. Repeated below are instructions for completing this block.

Block 17

Name of Referring (or ordering) provider, is completed when a patient is referred by his or her provider to another provider for services. This block should not be used to indicate a referral to a provider by a non-provider (e.g., a family friend has recommended that the patient seek your services). The correct format for completing this block is last name, first name, middle initial. Please omit titles or degrees (e.g., OD or MD.) and punctuation.

Claims Scanning

HMSA's claims scanner allows us to automatically enter clearly presented information from your claims into our claims processing system. When we use this equipment, we can process your claims promptly and avoid data processing errors. Claims that cannot be scanned must be manually entered into the claims processing system. You can facilitate the timely, accurate processing of your claims by:

• Typing or computer printing your claim.
• Using black or dark blue ink.
• Not using highlighter.

Prompt Claims Filing

Please remember that it is important to file your claims on a timely basis. Claims that are not filed within one year of the date of service are not payable. This time frame also applies when HMSA is your patient's secondary insurance carrier.

Claims for members of the Federal Plan (coverage code 87) must be submitted by the end of the year following the year during which services were rendered (e.g., services rendered in July 2011 must be submitted before December 31, 2012).

An exception may be made to the one-year filing-time limitation when HMSA is secondary to Medicare. In such a case, you must file your claim for secondary benefits within one year of the date Medicare paid or denied the claim. In most cases, Medicare will automatically submit your secondary claim to HMSA and will indicate this on your Medicare Remittance.

Even though filing limitations for the above-referenced plans may be extended beyond one year under certain conditions, it is to your advantage to file your claims in a timely manner.

Revision History