Fillable MassHealth - Vision Care Material Order Form

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MassHealth - Vision Care Material Order Form

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
MassHealth
Physician Bulletin 92
February 2012
TO: Physicians Participating in MassHealth
FROM: Julian J. Harris, M.D., Medicaid Director
RE: Updated Vision Care Material Order Form
Background In accordance with newly established 5010 HIPAA transaction standards,
all MassHealth claim submissions must include a valid diagnosis code,
effective January 1, 2012. This requirement also applies to the Vision
Care Material Order form (VIS-1).
Updated VIS-1 Order For MassHealth’s vision care contractor (MassCor) to comply with these
Form new HIPAA claim standards, VIS-1 order forms must now include a valid
diagnosis code. The VIS-1 has been revised to reflect the new
requirement. You can copy the attached VIS-1 form or download a copy
from the MassHealth Web site at www.mass.gov/masshealth
. In the
Publications panel on the lower right side of the home page, click on
MassHealth Provider Forms. You must make a copy of your completed
VIS-1 form before mailing or faxing the original form to MassCor and keep
it in your records. (The mailing address and fax number appear on the
form.)
Duplicate VIS-1 Duplicate VIS-1 form submissions are unnecessary and hinder the
Requests processing of all requests. Once you have submitted a VIS-1 form to
MassCor, please do not submit duplicate orders. Please allow MassCor
at least one week to complete the original order before you contact them
to check the status of your request. To check the status of an already-
submitted request, call 1-888-482-7331.
Updated Vision Care MassCor and MassHealth are pleased to announce that the available
Materials Catalog eyewear frame models will be updated effective January 1, 2012. Contact
MassCor at 1-888-482-7331 to request copies of the new MassHealth
Vision Care Materials Catalog.
Questions If you have any questions about the information in this bulletin, please
contact MassHealth Customer Service at 1-800-841-2900, e-mail your
inquiry to providersupport@mahealth.net
, or fax your inquiry to
617-988-8974.
Vision Care
Material Order Form
T H E C O M M O N W E A LT H O F M A S S A C H U S E T T S
Executive Office of Health and Human Services
VIS-1 (Rev. 01/12)
Homeless Person
Mail this form to:
MassCor/Massachusetts Correctional Industries
P.O. Box 466
Gardner, MA 01440
Inquiry Telephone: 1-888-482-7331 Orders Fax: 1-888-698-2020 and 1-888-420-2047
Provider No.: Group Practice No.:
Provider Name:
Street:
City: State: Zip:
Telephone No.:
Member’s Name: Date of Birth:
Last First MI
Member’s MassHealth ID No.: Gender: M F
Prior Authorization No.:
Date Sent:
Frame Name: No.: Frame Color: No.: Alternate Color: No.:
Eye Size: Bridge Size: Temple Length:
LENS TYPE – Please check Plastic Poly-C Other (Non-contract material)
single vision
bifocal rd seg flat top 28 ( )
lenticular aspheric sv rd seg
COMPLETE IN MINUS CYLINDER
SPH CYL AXIS PRISMS BASE DECENTER
IN OUT
DIST R
RX
L
Segment Height Inset Total Inset PD
Add for near R R R Far
L L L Near
Date Shipped: Date Received:
Special Instructions:
Color
pink 1 C1
pink 2 C2
Other C3
(See regulations at 130 CMR
402.000, accessible at
www.mass.gov/masshealth.)
Send original to MassCor. Keep a copy for your records.
Diagnosis Code
367.0 – Hypermetropia
367.1 – Myopia
367.20 – Astigmatism
367.4 – Presbyopia
I certify that the information on this form, and any attached statement that I have provided, has been reviewed and signed
by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties
or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
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Date:
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MassHealth - Vision Care Material Order Form

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Completed 19 May 2020

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