How VSP Reviews the Claim
VSP will review your claim and notify you or your provider in writing within the following time frames:
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Within 15 days for pre-service claims (within 30 days if an extension is filed). Pre-service claims are those where VSP requires you to obtain approval of the benefit before receiving the care. VSP may ask for a one-time extension of 15 days to request additional information. Once notified of the extension, you have 45 days to provide any missing information.
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Within 30 days for post-service claims (within 60 days if an extension is filed). Post-service claims are claims that aren't pre-service. VSP may ask for a one-time extension of 30 days to request additional information. Once notified of the extension, you have 45 days to provide any missing information.
The claim administrator reviews your claim, applying plan provisions and discretion in interpreting plan provisions, and then notifies you of the decision within the time frames listed above.
If VSP Approves the Claim
If the claim is approved and there is no indication that the bill has been fully paid, payment for covered services is made to the provider. If the bill indicates that full payment has been made to the provider, payment for covered services is made directly to you.
If VSP Denies the Claim
If the claim is denied, you'll be notified in writing of the reasons for the denial, the right to appeal and the right to obtain copies of all documents related to the claim that VSP reviewed in making the determination. (For information about appeals, see " Vision" in "Health Care Plans" in "Claims Review and Appeals Procedures" in Rules, Regulations and Administrative Information.)
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