VES. The Victorian eyecare service MANUAL OF PROCEDURES AND CONDITIONS FOR RURAL SERVICE PROVIDERS

Transcription

1 VES The Victorian eyecare service MANUAL OF PROCEDURES AND CONDITIONS FOR RURAL SERVICE PROVIDERS 2016 The Victorian Eyecare Service supports local partners to make quality eye care affordable to Victorians in need. VES is funded by the Government of Victoria and is administered by the Australian College of Optometry

2 TABLE OF CONTENTS 1 What is the Victorian Eyecare Service (VES)? 3 2 Who is eligible for VES benefits? 3 3 Where can VES benefits be accessed? 4 4 How are VES benefits accessed in country Victoria? 4 5 What are the VES benefits? 5 6 How are VES claims for subsidy made by providers? 5 7 Examination prior to issue of a claim form 6 8 Priority issue of a claim form 7 9 How the VES Office processes manual and online applications 7 10 What spectacle frames can be used? 8 11 VES subsidy for glasses 9 12 VES subsidy for contact lenses Quality assurance Modification of original prescription Schedule of fees Prescriptions written by others How to become a participating provider Practitioner numbers Resolution of complaints Enquiries Appendices 15 1 Schedule of patient contributions 15 2 Non-standard frame related costs 16 3 Vision Australia locations 16 4 Scheduled fees for VES claim forms 17 5 VES information leaflet and manual claim form application 18 6 Group application for claim form 20 7 Manual claim form for subsidy 21 8 Form for priority issue & additional entitlement 22 9 List of approved standard frames IT VES Manual Practice guide to online claiming Victorian Aboriginal Spectacle Subsidy Scheme (VASSS) Form for requesting approval for contact lenses 11 List of ineligible postcodes 12 Directory of participating practices, Optometrists and Ophthalmologists September

3 1 What is the Victorian Eyecare Service (VES)? The Victorian Eyecare Service (VES) supports local partners to make quality eye care, including vision aids (glasses, contact lenses, low vision devices), affordable to eligible Victorians. Eye examinations are provided by the Australian College of Optometry (ACO) in metropolitan Melbourne and by participating optometrists and ophthalmologists in rural and regional Victoria. The service is funded by the Government of Victoria through the Department of Health and Human Services (DHHS) and is administered by the ACO. It relies on the goodwill and continued participation of local partners throughout rural and regional Victoria. Under the service, bulk-billed Medicare benefits are accepted by participating optometrists so that patients pay no fees for optometric consultations. Benefits for consultations by ophthalmologists may be bulk-billed, or if patients are charged a fee it will be no more than the amount of the Medicare rebate. Patients make a contribution toward the cost of any glasses, contact lenses or low vision devices provided and the VES meets the balance of the cost. 2 Who is eligible for VES benefits? People are eligible for VES benefits if they are permanent residents of Victoria and either: hold or are listed on a current Health Care Card (and have done so for at least 6 months); or hold a Pensioner Concession Card; or are under the age of 18 years and in Out of Home Care identify as an Aboriginal or Torres Straight Islander (ATSI) person. Dependents under the age of 18 years, named on a card, are also eligible provided they are permanent residents in the State of Victoria. People who are not listed on one of these cards or who are not permanent residents of this state cannot be provided with vision aids under the VES. Holders of Seniors Commonwealth Health Care Cards are not eligible. Participating optometrists are required to check the eligibility of patients by sighting their benefits card before making any claims for VES benefits. People of ATSI heritage are not required to hold a current Health Care or Pensioner Concession Card to utilise the VES under the Victorian Aboriginal Spectacle Subsidy Scheme (VASSS). More information on the VASSS can be found in Appendix 14. Residents of NSW and SA who live close to the Victorian border Some NSW and SA residents live close to the Victorian border. These persons are not eligible for VES benefits but are eligible for benefits under similar schemes in their own State. Residents of New South Wales may be referred to the NSW Government Spectacles Program which is administered by Vision Australia, telephone and ask for spectacles at the voice prompt or info@visionaustralia.org. South Australian residents may be referred to The Manager, SA Spectacle Scheme, GPO Box 292, Adelaide SA 5000 (Telephone ). Transients from other states are also not eligible even though they may live for some time in a Victorian country area. September

4 3 Where can VES benefits be accessed? Australian College of Optometry Eligible patients can attend the ACO clinic in Carlton and receive VES benefits, regardless of their address in Victoria. The ACO also provides VES at the Broadmeadows Health Service, the Darebin Community Health Centre East Preston, the Cardinia-Casey Community Health Centre Berwick, Frankston Integrated Health Service and the Western Region Health Centre Braybrook. Patients who wish to attend any of these ACO Clinics can make an appointment by phoning: Rural VES (03) or writing to: Optometry Clinic Australian College of Optometry Cnr Keppel & Cardigan Streets Carlton VIC 3053 People who reside outside of Melbourne may attend one of the optometrists or ophthalmologists who have agreed to participate in the VES. There are over 200 participating rural practitioners who provide services in most of the provincial cities and towns throughout Victoria. The Directory of participating practices, Optometrists and Ophthalmologists (Appendix 12) details the localities from which VES services are available at the date of publication (shown in page footer). In order to obtain VES service in the country, patients must be permanent residents of rural or regional Victoria, not short-term residents or visitors from Melbourne or elsewhere. Rural VES ineligibility is covered in Appendix 11, with the postcodes of the areas designated as part of the Melbourne metropolitan area listed. People living in any of these postcode areas MUST attend one of the clinics of the ACO to access VES. People living in Victorian postcode areas NOT listed in Appendix 11 may access VES from a VES rural partner practice. Some exceptions do apply with a range of postcodes able to access Rural VES or metropolitan clinic services. In appropriate circumstances, eligible patients can also be referred to one of Vision Australia s Low Vision clinics (see Appendix 3) where VES is also available. 4 How are VES benefits accessed in country Victoria? Eligible patients can access VES benefits by applying for a claim form in writing or claim number online. Written applications should include the candidates full name, address, type and entitlement number of their benefit card and how long they have held their card. The correspondence should be directed to: Victorian Eyecare Service Australian College of Optometry Cnr Keppel & Cardigan Streets Carlton 3053 If the application is successful, a claim form (Appendix 7) will be allocated. Alternatively, applications can be lodged electronically on the VES website ( This will automatically check for VES eligibility and provide a claim number instantly if the application is accepted (see Appendix 13 - IT VES Manual Practice guide to online claiming for further information). Practices can also make claims for a claim form or electronic claim number on the patient s behalf using the Group application form (see Section 7 for further information) or online system (see Appendix 13), respectively. Patients should be given the copy of the information leaflet, which outlines the VES and pricing (see Appendix 5). September

5 Applications for a claim form or numbers cannot be accepted by telephone, by the ACO or by practitioners making a Group application. 5 What are the VES benefits? The VES provides assurance to patients that they will receive optometric care at a known affordable cost so they will not be deterred from obtaining eye care because of uncertainty about expenses. The following three points are fundamental to the VES. No direct payment of consultation fee Bulk-billed Medicare benefits are assigned for all consultations provided to eligible patients who seek optometry care under the VES. The exception to this is a professional attendance of more than 15 minutes duration, being the first in a course of attention where the patient has attended another Optometrist within the previous 24 months and does not qualify for 10910, 10911, 10905, or In this case, where a is the appropriate item number, the participating Optometrist may charge the patient a consultation fee equal to the Medicare benefit for an item 10910/ Medicare will refund half of this to the patient. Ophthalmologists undertake either to bulk-bill their VES patients or to charge no more than the fee rebatable by Medicare. Affordable glasses and contact lenses When glasses and contact lenses are clinically necessary, they are subsidised by the VES and the patient pays no more than the amounts shown in Appendix 1. Patient contributions are updated at the beginning of each financial year. No "add on" charges or extras The fees in Appendix 1 are the only fees to be paid by patients. However, patients may elect to purchase a non-standard spectacle frame, in which case they pay the normal cost of the spectacle frame plus the contribution for lenses as shown in Appendix 1 (See Section 10). Under no circumstance must patients pay add-on charges (e.g. for tints, coatings etc.) for VES subsidised glasses. The only exception to this is where photochromatic glass single vision or bifocal lenses are clinically necessary and prescribed. An additional contribution from the patient in accordance with Appendix 1 is permissible. Please note that photochromatic multifocals are not accessible under the VES. 6 How are VES claims for subsidy made by providers? Once a claim form or claim number has been supplied, claims for VES subsidy for glasses or contact lenses can be made manually or electronically. For information on how to lodge a claim electronically see Appendix 13 IT VES Manual Practice guide to Online Claiming, and contact the VES Office to arrange setup. For manual claims, once a claim form is obtained the process it outlined below. Check patient eligibility The participating provider must check the patient's eligibility before signing or processing a claim form. (1) Check that the patient holds or is listed on a Health Care Card to ensure that they are entitled to VES subsidy. If a Pensioner Concession Card holder, check the patient s own name is listed on the card, unless the patient is a dependent under 18 years of age. (Please note that subsidy is not applicable to Commonwealth Seniors Card Holders) (2) Check that the card is currently valid. (3) Transcribe the entitlement number to the claim form. September

6 (4) Check that the permanent address of the patient is in Victoria and in the country VES region. The address on the entitlement card must be the same as the address on the claim form. See Appendix 11 for a list of ineligible postcodes. Note that the eligibility criteria for the Victorian Aboriginal Spectacle Subsidy Scheme is quite different refer to Appendix 14 for any patient who identifies as Aboriginal or Torres Straight Islander. Never make a claim for a patient whose normal address is in the metropolitan area or in a State other than Victoria. Claims cannot be paid if the patient is not eligible. Provider must sign Claim forms must be completed in full. They must show the provider's number for the participating optometrist or ophthalmologist at the particular location at which the examination was conducted, and be signed by the attending practitioner. Patient must sign at delivery The patient must sign that the visual aids have actually been delivered and that they have paid a fee no more than the prescribed patient contribution. Post claims to: Victorian Eyecare Service Australian College of Optometry Cnr Keppel & Cardigan Streets Carlton 3053 Batches of claims should be submitted regularly, preferably weekly and not less than monthly. Claims received before the 20th day of the month will normally be paid in the first week of the following month. The claim form has two copies: (1) The top white copy is the claim form (2) The yellow copy is the provider s record Making false declarations is a serious offence. 7 Examination prior to issue of a claim form On occasion, an examination could be provided prior to the issue of a VES claim form. This may occur because the patient is unaware of the VES and will be told by the provider about the subsidy. Providers may act as follows: Delay the prescription and supply of glasses until the claim form is received, if there is no clinical urgency, or Prescribe and supply the visual aids prior to the issue of a claim form provided that the patient pays only the VES patient contribution. Apply for a claim form on the patient s behalf using the Group application form (Appendix 6) or lodge a claim electronically for a claim number on the patient s behalf and proceed with online claiming for the order. Patients should be given an application form, which explains the rules and costs of the VES. Providers making an application on the patient s behalf must sight the patient s pension or health care card and certify that they have made this check of eligibility Providers should note that if they make up glasses prior to the issue of a claim form and the patient fails to collect the glasses, no subsidy is payable. Glasses must be delivered to the patient before subsidy can be paid. Manual claim forms require a patient signature to verify collection. Providers may not charge their full fee (either the VES schedule fee or their normal private fee) and refund moneys when the VES pays the subsidy. September

7 8 Priority issue of a claim form Providers may apply for priority issue of a claim form when they consider that there is an urgent and clinically justifiable need for glasses to be provided to a patient without delay. If claiming manually, all details must be completed on the Special Request form with priority highlighted before a claim can be considered. The priority claim form is included (Appendix 8). Priority claims for prescription changes can be lodged using the VES online claiming system. Priority claims for replacement of lost or damaged glasses within two years and for contact lenses is done manually only. The normal criteria for priority issue are: replacement of lost or irreparably damaged glasses when the patient has no useable spare (only one pair of replacement glasses with surcharge is available within a two year period). the provision of glasses for the first time where: - the power of the glasses is +1.00DS or more or -0.75DS or more (expressed in terms of equivalent sphere) - a cylindrical correction of 1.25D or greater or anisometropia of 1.00D or greater and - a significant improvement in visual acuity in a distance prescription. a need for a change of refractive correction of at least -0.50DS at distance or +1.00DS at distance or near (expressed in terms of equivalent sphere) and improves visual acuity by full one line or more. a change of prism correction greater than 3.75 horizontally or 1.75 vertically. 9 How the VES Office processes manual and online applications Manual applications: (a) The application is checked to ensure all the information needed is provided. We write to the applicant if it is not, provided the applicant provides a return address. (b) The eligibility of the applicant is checked. If the applicant is not eligible because they are not resident in country Victoria or they do not hold or are listed on a qualifying pension or health care card, the application is declined and the applicant notified. (c) Past VES benefits are checked. If VES benefits have been paid in the last two years, the application is declined since VES benefits are normally available only once every two years unless there is certification of clinical need (see Section 11). (d) If the application is in order, a claim form is generated immediately and issued to the patient via mail with instructions to present the form to their local VES provider. A booklet listing all VES participating providers is given if necessary (Appendix 12). Patients are encouraged to seek advice from a participating provider without delay if they consider they need urgent eye care (see Section 8). Online applications: Note Electronic lodgment of applications provides an immediate decision on the application status, with a letter or claim automatically generated for the applicant. Online applications generate a claim number to be used when VES providers lodge a claim electronically. Applicants wishing to make an online application should visit It is essential that patients take their claim form or print out of electronic claim number, their Medicare card and their pension or health care card with them to the eye examination. Patients make their own appointment to see a participating provider of their choice. September

8 The VES claim form and electronic claim number is valid only for six months from date of issue. The issue of a claim form or electronic claim number is not proof of eligibility. VES providers must sight and check the patients pension or health care card before making a claim and must not make a claim if the card is not one that confers eligibility or if it is no longer current. Claim forms are always posted to the home address of the applicant. Claim forms can only be sent to a post office address if the residential address is given. They can be sent direct to the provider only in exceptional circumstances. 10 What spectacle frames can be used? Standard frames Participating practices must offer patients a choice of at least two standard metal and two standard shell frames from each category (mens, ladies, childrens and unisex), along with at least one standard lookover frame. These frames must include varied styles and a choice of suitable colours for each frame type. The approved standard frames are listed in Appendix 9. VES standard metal frames will be available from November Participating practices or suppliers may submit to the VES Office other frames for approval at any time. Frames are judged on the basis of quality of manufacture, appearance, range of sizes and colours and suitability for VES eligible patients. Frames in one colour or one size are normally not approved. Non-standard frames Supply of non-standard frames Patients are free to choose a non-standard spectacle frame instead of a VES standard frame. In this case they pay the normal cost of the spectacle frame and contribute to the cost of the lenses as set out in Appendix 1. Under no circumstances should any pressure be put on patients to select a non-standard frame. If VES standard frames are unsuitable for good clinical reason, then subsidy can be provided for a special frame (see below). Supply of non-standard frames when standard frames are not clinically acceptable Occasionally standard frames will not be clinically suitable. This might occur when there is an established allergy to plastic frames or when there is a facial lesion or anomaly that requires a frame with pads. In these circumstances a non-standard frame may be supplied. The frame supplied should be the frame with the lowest wholesale price that meets the patient needs. When the need for a non-standard frame arises the optometrist must or write to the VES Office setting out the clinical indications for the non-standard frame, the name and details of the frame to be supplied and the wholesale cost of the frame. After approval is received, a claim for the wholesale cost of the frame plus a VES contribution fee (Appendix 2) is made on the standard claim form. The patient pays no additional charge. Supply of non-standard frame to dependent children of eligible patients under the age of 18 yrs Standard spectacle frames may not fit some children adequately or may for other reasons not be suitable. When this occurs it is possible to obtain a subsidy for the supply of a non-standard children's frame up to a specific wholesale cost (Appendix 2) plus VES contribution fee (Appendix 2). The lowest cost frame that meets the child's needs should be supplied. Prior approval is necessary only when this limit is exceeded. When claiming, a note from the provider on practice letterhead must be attached to the claim form stating: (1) that the patient is under the age of 18 years and is a dependent of an eligible person; September

9 (2) the reason why no standard frame is suitable; (3) spectacle frame details; and (4) wholesale cost of the frame. Use of own previously used frame Where appropriate patients may opt to reuse their old frames. The provider may refuse to fit VES subsidised lenses to a patient s own frame when: - reusing rimless, nylon and faceted lens frames due to the higher cost of fitting; - the frame requires specially ground lenses when stock lenses could be fitted to a standard frame; - reglazing standard frames over two years old; or - the frame is not in good enough condition or is in some way clinically unsuitable for the patient. Use of a new un-used frame If a patient presents with a new unused frame, the patient contribution for the supply and fitting of lenses is the same as if a new non-standard frame had been supplied. The claim form is to be annotated accordingly. Participating providers have the right to refuse the use of such frames. Providers are reminded that the VES does not permit patients to pay extra charges. Patient contributions must not exceed those specified in Appendix VES subsidy for glasses VES subsidy is available once every two years from the date of collection of glasses, provided that new lenses or new glasses are clinically necessary. The VES subsidy is available to eligible patients for: one pair of reading glasses and one pair of distance glasses, or one pair of bifocal glasses, or one pair of multifocal glasses. No VES subsidy is payable if: The patient's own frame is a rimless frame, a nylon rim frame, or a faceted lens frame. The patient's own frame has a large eye size and requires ground rather than stock lenses unless the large eye size is required to ensure a proper fit. No VES subsidy is payable for: resin photochromic plastic lenses (Note: glass single vision and bifocal photochromatic lenses which are included with certification of clinical necessity); tinted or photochromatic lenses without certification that the tint is clinically necessary; trifocals and vocational multifocals; bifocal, piggyback and haptic contact lenses; non-spectacle low vision aids; glasses or a change of glasses that are judged by the attending practitioner not to be clinically necessary. September

10 Subsidy of clinically necessary glasses within two years Approval may be given for subsidy to be paid more frequently than once every two years if the prescribing provider is able to certify that new lenses or glasses are clinically necessary. This applies to those people who have had a substantial change of refraction due to a changed clinical condition. Replacement of lost or irreparably damaged glasses Approval may be given for subsidy to replace lenses or glasses that have been lost or irreparably damaged once within two years of the last claim for VES subsidy. Patients seeking VES subsidy for lost or broken glasses are required to sign a declaration stating that their glasses were accidentally lost or broken and that they have no usable spare pair. When the frame of broken glasses is undamaged, subsidy is paid only for the replacement of the broken lens or lenses. A surcharge (see Appendix 1) is payable for the replacement of lost or broken glasses, or lenses, within two years of the previous VES subsidy Subsidy of glasses additional to reading and distance glasses or bifocals In exceptional circumstances a subsidy may be approved for glasses additional to bifocals or reading and distance glasses. Approval is most likely when the special need for additional glasses arises because of physical impairment. Patient convenience or preference is not sufficient reason for the provision of subsidy for any glasses additional to reading and distance glasses or bifocals. How to obtain approval for additional entitlement to subsidy within the two-year period Complete all details on Special Request Form (Appendix 8) or write a letter of explanation on your practice letterhead including all the necessary details. Be sure to give sufficient clinical information to justify the additional entitlement. Send the form to the VES Office, certifying the clinical need. If the request is approved, a claim form will be issued and sent to the patient. Special requests due to change in prescription can be lodged using the online claiming system. Special requests for damaged or lost glasses, or contact lenses are to be done manually. 12 VES subsidy for contact lenses VES subsidy for contact lenses is available to eligible patients if they meet the additional criteria of: myopia equal to or greater than 6.00 D in one or both eyes; hypermetropia equal to or greater than 5.00D in one or both eyes; astigmatism equal to or greater than 3.00D in one or both eyes; irregular astigmatism in one or both eyes with visual acuity of less than 6/12 when corrected by spectacles provided that acuity improves by one line of visual acuity on the logmar chart when contact lenses are worn; a need to occlude or partially occlude an eye to eliminate distortion or diplopia arising from an ocular anomaly or injury; a need to provide cosmetic improvement to serious ocular deformity or such other conditions that qualifies for a Medicare Benefit under item VES subsidy for spherical and toric disposable contact lenses is available on clear clinical justification, but is payable no more than once every six months. Subsidy is not paid for bifocal, piggyback or haptic contact lenses. Prior approval must be obtained. September

11 If one of the conditions above is met and VES subsidy is sought, the provider must send a report justifying the prescription and provision of contact lenses under VES subsidy to the VES Office. The form to obtain approval is attached (Appendix 10). If the application is approved, a letter of approval will be issued to the provider. This must be attached to the VES claim form when it is submitted for payment. Patients receiving VES subsidy for contact lenses may also receive subsidy at the same time for distance and reading glasses or for bifocals. 13 Quality assurance Practices providing services for the VES are required to adhere to agreed practice standards as discussed during the application process. Optometrists must be registered with the Optometry Board of Australia and adhere to their Code of Conduct for Optometrists. VES providers are expected to take direct responsibility for the quality of both consulting and dispensing services provided through the VES. They are expected to always use their best endeavors, both at the initial consultations and in follow-up visits, including those relating to the supply of visual aids, to ensure their patients vision difficulties are resolved and that the visual aids prescribed and supplied are satisfactory. All ophthalmic materials must be of good quality and finish in accordance with usual professional standards. Spectacle lenses must conform to the Australian Standard AS/NZS 21987:2011 Ophthalmic Optics Mounted Spectacle Lenses and any subsequent amendments. 14 Modification of original prescription For some patients, modification of the first prescription for glasses is necessary because of error in refraction, an error of judgment in deciding on the form of the prescription or because of an error in dispensing. When an optometrist is the prescribing provider, the cost of changing lenses will be borne by the provider in accordance with usual practice. When an ophthalmologist is the prescribing provider and glasses are dispensed by another practice, the full cost of the change to correct an error of refraction will be reimbursed by the VES in accordance with the scheduled fee. Patients make no further contribution should lenses need changing because of an error in clinical judgment by providers in writing the initial prescription. Providers must be as willing to identify the cause of any problem with glasses supplied under the VES and to make amendments, as they are with their private patients. When an ophthalmologist issues a new prescription to correct an error in the first prescription, the dispensing provider requests a VES claim form using the special request form. In this case the claim form is sent directly to the practice. 15 Schedule of fees Participating optometrists agree to accept payment of the schedule of fees as full payment of the visual aids supplied. The fees are outline in Appendix 4 and are set by the Minister for Health. The schedule of fees is made up of the VES subsidy and the patient contribution. Thus VES subsidy is the difference between the scheduled fee and the patient contribution. In the schedule of fees for glasses, stock lenses are defined as lenses of power up to ±6D or -2D cyl. No differentiation is made in the fee schedule between glass and CR39, nor between forms of bifocal. September

12 Providers may prescribe different lens materials and lens forms according to their best clinical judgment provided the scheduled fee is accepted as full payment and there is no departure from the scheduled patient contribution. Mixed stock and grind lenses Where one lens is a stock lens and the other a grind lens, the scheduled fee is the sum of half of the scheduled fees for the two items. 16 Prescriptions written by others The VES is an integrated scheme of service delivery that provides consultative services at no cost to the patient through assignment of benefits, and provides affordable glasses and contact lenses as clinically necessary. Aids cannot be provided under the VES when the prescription has been written by a non-participating provider. This would undermine the systems of cost control and quality assurance. 17 How to become a participating provider Optometry practices To be eligible to participate in the VES, the practice must: (1) Employ Optometrists who are registered with the Optometry Board of Australia and adhere to the Code of Conduct for Optometrists; (2) Adhere to the ACO s Code of Ethics or the practice s own code of ethics, which has been approved by the ACO during the application stage; (3) Be located in country Victoria in a region designated by the VES committee as a region within which VES services can be provided (Appendix 11 lists the postcodes of those areas outside the designated areas); (4) Must provide integrated consulting and dispensing services; (5) Agree to bulk bill Medicare for all consultations provided to eligible patients who seek eye care under VES. The exception to this is an optometry consultation of more than 15 minutes duration, being the first in a course of attention where the patient has attended another optometrist within the previous 12 months (if aged at least 65 years) or 36 months (if aged less than 65 years) and does not qualify for 10905, or In this case, where a is the appropriate item number, the participating optometrist may charge the patient a consultation fee equal to the Medicare benefit for an item 10910/10911; (6) Agree to supply, as clinically needed, spectacles in approved frames and contact lenses, in accordance with the current VES Manual of Procedures and Conditions. This includes agreement to accept the fixed co-payment made by the patient as part of the schedule of fees as subsidy by the State Government. The patient contribution and VES subsidy is to be accepted as full payment for spectacles or contact lenses under the scheme; (7) Take direct professional responsibility for the quality and satisfactory performance of those spectacles or contact lenses; (8) Agree to provide VES subsidised services only from those Service Provider locations approved by the VES; (9) Agree to provide supplementary information to the VES or Clinical Services Committee as may be required for the purposes of an audit or if there is reason to believe there may have been a breach in the conditions of participation or a breach of professional standard; (10) Accept that the VES committee may admit as a participating VES provider, an optometrist whose main place of practice is in metropolitan Melbourne and who provides a visiting service to a September

13 country town, provided that the service is provided at least once every two weeks and the locality in question would otherwise not have ready access to VES subsidised services; (11) Agree to notify the VES Office of any changes to the ownership of the practice or any change of address or any significant change in the method of operation of the practice no later than one month after those changes have occurred. Ophthalmology practices To be eligible to participate, privately practising ophthalmologists must: (1) Be a registered Ophthalmologist with the Medical Board of Australia; (2) Have a full time rural practice or visit a hospital for surgical sessions in a country region on a regular basis; (3) Agree to assign benefits for all consultations provided to eligible patients who seek ophthalmological care under the scheme or charge a fee that is no more than the amount of the Medicare rebate. Providers who wish to participate in the VES should contact the VES Office. Participation of a provider or practice may be revoked if the conditions of participation are breached. Providers should indicate at the time of application if they also wish to participate in the Victorian Aboriginal Subsidy Scheme (VASSS) as per the information contained in Appendix Practitioner numbers On approval, participating practitioners are given a practitioner number for each address at which they provide VES service. The numbers identify the practice, practitioner and the region in which the VES service is provided. Practitioners must take care to use the correct number since the number is important to the processing and payment of claims and preparation of statistical data for the Department of Health and Human Services (DHHS). 19 Resolution of complaints The practice should seek to resolve patient concerns and complaints in good faith and within 21 business days by discussion and conciliation. The practice should notify ACO of any known unresolved patient complaints. Upon request, the ACO will provide assistance and advice to the practice and patients with the view to complaints resolution. Complaints will be dealt with in the first instance by the VES Office and where necessary the Director of Clinical Services of the Australian College of Optometry. Request for assistance, from a practice or patients to the ACO, should be responded to within 5 business days and resolved within 21 business days. It is appropriate for the Department of Health and Human Services to play a formal role in complaints that cannot be resolved with the service provider, or are raised by service users who feel that they are unable to approach the service provider directly. Service users can contact the department on or complaints.reception@dhhs.vic.gov.au For further information on the Department s complaints and feedback process visit this website for further details The patient has the right to make a complaint to the Health Services Commissioner at any time and if they are unsatisfied with the outcome of the complaints handling process. September

14 20 Enquiries Questions about application to be a participating VES optometrist or ophthalmologist, VES procedures, and all other VES enquires should be directed to: The VES Office (03) or ves@aco.org.au September

15 21 Appendices Appendix 1 - Schedule of patient contributions (effective 1 July 2016) Item 1 Patient contribution Reading or distance lenses in standard shell frame (with case) $40.00 (+ $3.30 GST) Bifocal lenses in standard shell frame (with case) $55.00 (+ $3.30 GST) Progressive lenses in standard shell frame (with case) $97.50 (+ $3.30 GST) Reading or distance lenses in standard metal frame (with case) $50.00 (+ $4.30 GST) Bifocal lenses in standard metal frame (with case) $65.00 (+ $4.30 GST) Progressive lenses in standard metal frame (with case) $ (+ $4.30 GST) Reading or distance lenses to own previously used frame $18.00 Bifocal lenses to own previously used frame $33.00 Progressive lenses to own previously used frame $71.50 Reading or distance lenses to a new non-standard frame $40.00 Bifocal lenses to a new non-standard frame $55.00 Progressive lenses to a new non-standard frames $97.50 Photochromatic reading or distance lenses 2 $18.50 Photochromatic bifocal lenses 2 $27.00 Contact lenses 3 $55.00 Replacement of spectacle frame (Standard VES frame) $33.00 (+ $3.30 GST) Replacement of spectacle frame (Standard VES metal frame) Surcharge for replacement of glasses or lenses broken or lost within 24 months of the last VES subsidy $43.00 (+ $4.30 GST) $18.00 Notes: 1 If only one spectacle lens is prescribed or only one eye is supplied with contact lenses, half the fee is payable 2 Payable in addition to reading/distance/bifocal lenses where glass photochromatic lenses are clinically necessary. Certification and justification is required. 3a Conventional or RGP lenses: pair of lenses with appropriate starter kit of cleaning solutions including case 3b Disposable contact lenses: 90 pairs of daily disposable lenses or 6 month supply of fortnightly or monthly lenses for 2 eyes with an appropriate contact lens starter kit including case September

16 Appendix 2 Non-standard frame related costs (effective 1 July 2016) Item Supply of non-standard frame to dependent children of eligible persons under the age of 18 yrs Cost up to $50 (excl. GST) VES contribution fee $6.50 Appendix 3 Vision Australia locations From 1 April 2016 optometry services at Vision Australia were ceased and as such patients can no longer access VES through any Vision Australia site. September

17 September Appendix 4 - Scheduled fees for VES claim forms (effective 1 July 2016) Item No. Item description 1 Definition Fee 1 Single vision stock lenses up to -6D / +4D sph or -2 D cyl 2 $ Single vision grind lenses from -6D / +4D sph or -2D cyl to ±10D sph or -4D cyl $ Single vision aspheric or lenticular lenses greater than ±10D sph or -4D cyl $ Bifocal lenses (R seg or D seg) up to ±9D or -4D cyl $ Bifocal aspheric lenses greater than ±9D sph or -4D cyl $ Progressive lenses $ Tints (surface or solid) 4 $ Photochromatic glass single vision 4 (in addition to Item No 1 or 2) $ Photochromatic glass bifocal 4 (in addition to Item No 4) $ Standard shell frame inclusive of case $ Standard metal frame inclusive of case $ Contact lenses 7 Spherical Hard 5 materials 3 + invoiced cost of $ Contact lenses 7 Toric Hard/Soft 5 materials 3 + invoiced cost of $ Contact lenses 7 Spherical Disposable 6 $ Contact lenses 7 Toric Disposable 6 $ Notes: 1a 1b Contact lenses 7 Soft (spherical) Conventional 5 $ If only one spectacle lens is prescribed or only one eye is supplied with contact lenses, half the fee is payable Fees for any spectacle lenses include the cost of fitting to a frame 2 If prescribed prism is more than 4 and the prism cannot be dispensed by decentration so that grind lenses must be ordered, then item 3 or item 5 can be claimed (aspheric lenses). In this instance, the optometrist should attach a letter that gives sufficient detail (eg PD, frame name and size) to justify the claim. 3 Invoiced cost of materials is cost after any optical laboratory discount and can include a courier charge up to a maximum of $ Tinted and glass photochromatic lenses may be supplied only when clinically necessary. Certification and justification is required. Cost of tint or glass photochromatic tint is in addition to cost of lenses. 5 Conventional or RGP lenses: pair of lenses with appropriate starter kit of cleaning solutions including case 6 Disposable contact lenses: 6 month supply of fortnightly or monthly lenses for 2 eyes with an appropriate contact lens starter kit including case 7 Any contact lenses can only be supplied when the patient meets the eligibility criteria based on the following Medicare criteria: Myopia of 5.0D or greater (spherical equivalent) Manifest hyperopia of 5.0D or greater (spherical equivalent) Astigmatism of 3.0D or greater Irregular astigmatism Anisometropia of 3.0D or greater Prescribed as part of a telescopic system (VA 6/30) Opaque CL - pathological mydriasis, aniridia, iris coloboma, pupil malformation, corneal opacification Patients who have physical deformity unable to wear spectacles Patients who have a medical condition (other than listed above) requiring use of contact lenses 8 Standard metal frames available from November 2015

18 Appendix 5 - VES information leaflet and manual claim form application September

19 September

20 Appendix 6 - Group application for claim form VICTORIAN EYECARE SERVICE GROUP APPLICATION FOR CLAIM FORMS FOR PATIENTS ALREADY ATTENDING AN OPTOMETRIST PLEASE COMPLETE INFORMATION BELOW IN BLOCK LETTERS ** Please include residential address on a second line if postal address is a post office box number CARD NUMBER TYPE OF CARD (PCC/HCC) FAMILY NAME GIVEN NAMES (First Name and Initial) TITLE DOB ADDRESS** (Number and Street) TOWN POST CODE TYPE OF GLASSES (SVN/SVD/BF/MF) All the persons listed above have an appointment in my practice or have had a consultation. I certify that the health benefits card of the patient has been sighted by a staff member of the practice and that to the best of my knowledge none of the persons listed has had a benefit paid under the VES in the last 2 years. Practice name and address.. Optometristʼs name... Signature (original) of optometrist Date / / lyc/stationery 14/08/2009 September

21 Appendix 7 - Manual claim form for subsidy September

22 Appendix 8 - Form for priority issue & additional entitlement September

23 Appendix 9 - List of approved standard frames VES APPROVED FRAME LISTING Current as of LADIES' FRAMES MEN'S FRAMES CHILDREN'S FRAMES UNISEX LOOKOVER FRAMES COMPANY MODEL COLOURS SIZE MODEL COLOURS SIZE MODEL COLOURS SIZE MODEL COLOURS SIZE MODEL COLOURS SIZE APOLLO , , * , 54, 56, , 54, , 54, MODSTYLE FLO 3 50/52-18 KEVIN 2 51/53-18 BEV 3 44/ /50/52-18, 48/50/52/54-20, MERV 2 50/52/54-22 PETER /19 RIMOPTICS RIM /19 RIM /19 RIM /18 RIM TESS RIM /16 JUNIOR RIM /17 LISA AIDEN RAY DAVE Participating optometrists are required to offer a choice of at least 2 standard shell & metal frames suitable for women, 2 standard shell & metal frames suitable for men, 2 standard shell & metal suitable for children & unisex and at least 1 standard lookover frame A full range of sizes and colours should be available so that standard frames suitable and acceptable to patients can be provided (minimum 2 colours per frame style) Frames may be proposed at any time for approval by writing to the VES enclosing samples of the frame and colour and size range Standard metal frames are printed in red September

24 Appendix 10 - Form for requesting approval for contact lenses September

25 Metropolitan Melbourne Metropolitan Melbourne Metropolitan Melbourne Metropolitan Melbourne Appendix 11 - List of ineligible postcodes INELIGIBLE POSTCODES FOR VES RURAL Effective 1 st July Diggers Rest, Bulla, Sunbury, Wildwood, Clarkefield Kinglake Central, Kinglake West, Eden Park, Humevale, Whittlesea, Panton Hill, Smiths Gully, St Andrews 3775 Christmas Hills Metropolitan Melbourne 3644 Barooga, NSW Choice of VES RURAL or METRO CLINICS VES Rural or Berwick Metro Clinic VES Rural or Berwick Metro Clinic 3912 VES Rural or Berwick Metro Clinic VES Rural or Frankston Metro Clinic VES Rural or Carlton Metro Clinic VES Rural or Carlton Metro Clinic 3723 VES Rural or Carlton Metro Clinic 3757 Pheasant Creek only VES Rural or Carlton Metro Clinic VES Rural or Carlton Metro Clinic 3804 VES Rural or Carlton Metro Clinic 3833 VES Rural or Carlton Metro Clinic All applicants whose permanent address falls in the above localities, should be advised to telephone the optometry clinic at the Australian College of Optometry for an appointment. The appointment telephone line is September

26 Appendix 12 - Directory of participating practices, Optometrists and Ophthalmologists September

27 Appendix 13 - IT VES Manual Practice guide to online claiming September

28 VES The Victorian eyecare service IT VES MANUAL PRACTICE GUIDE TO ONLINE CLAIMING VERSION THE VICTORIAN EYECARE SERVICE BRINGS LOW COST OPTOMETRY SERVICES TO PEOPLE OF LIMITED MEANS. IT IS FUNDED BY THE GOVERNMENT OF VICTORIA AND IS ADMINISTERED BY THE AUSTRALIAN COLLEGE OF OPTOMETRY IT VES Manual Practice Guide to Online Claiming

29 TABLE OF CONTENTS Section Page 1 Overview 2 Applying for a claim 2 Validating a claim 2 Submitting a claim for subsidy under the VES 2 Notes 3 2 Login page 3 3 Home page 3 4 Apply for claim page 4 5 Validate a claim page 6 6 Claims to submit page 7 7 Submit a claim page 7 8 Submitted claims page 8 9 Payment of claims 9 10 Auditing 9 1 Overview The VES IT Rural system enables patients and VES participating practices to make VES applications online and for VES practices to lodge claims online for payment. Applying for a claim A patient can lodge an application online via the ACO website at Or VES practices can apply on a patient s behalf when they present at the practice, via the Practice home page on the VES website at Validating a claim Only claims applied for by the patient online need to be validated. The application details and pension card or health care card need to be validated by the VES practice when the patient presents to the practice. This is to ensure their identity and address is correct and valid. If the VES practice applies for a claim on the patient s behalf, the validation process already occurs during this process. Submitting a claim for subsidy under the VES Only applications completed online can be submitted online. Submitting claims online is a simple process and can fast track the payment. IT VES Manual Practice Guide to Online Claiming

30 Notes Only online application can be a part of these processes. Applications applied for, or validated at a practice cannot be validated or submitted at another practice. Nor can they be validated or submitted at another location for the same practice. Fields in red require data to be entered. 2 Login page Access to reach the login page (see Figure 1). Figure 1 Login screen A login ID and password to access the online system can be obtained from the VES Office. Only one login ID is available per practice, but any number of computers at a practice can use it. For practices with more than one location, a different login ID for each location is required. The login information only needs to be entered once per day. 3 Home page The home page is the next screen to appear and shows the practice details the VES Office has listed for the practice (see Figure 2). Check the details and click to send an to the VES Office with any changes required. It is important to keep the VES Office up to date with a current list of all practitioners working from each practice. IT VES Manual Practice Guide to Online Claiming

31 Figure 2 Home page 4 Apply for claim page Click on Apply for Claim on the menu bar, to access the page used to apply for a claim on behalf of a patient. IT VES Manual Practice Guide to Online Claiming

32 Figure 3 & 4 Loading a patient A valid pension card or health care card number and surname must first be entered. If Aboriginal/Torres Strait Islander patients do not hold a valid pension or health care card, then you may submit with a medicare card number instead. When a valid number is entered the red cross next to the field will change to a green tick. Once the button is clicked, the VES records are checked. If the card number is on record but linked to a different surname, an advisory message will appear on screen and the claim process will not proceed. If the card number is on record with a matching surname, the details of the patient will be displayed see Figure 5. Please check that the card is current and that the card details match the patient. Having done this, click the tick box labelled Card is currently valid. This tick box indicates the practice s declaration that the card is valid. If the address and other patient details need to be changed, please enter the correct details. If the patient has a claim in progress or is currently eligible for a claim, the Claim Type list will be inactive. If the patient is not currently eligible for a claim (and does not have a claim in progress), the Claim Type list will be active. This allows the practice to enter a Special Entitlement claim. This can be selected from the Claim type drop down menu and will allow the claim to proceed. In most cases, a reason for the special entitlement will need to be specified (See Figure 5). Additional entitlement claims for lost or damaged glasses that incur a surcharge cannot be applied for online. Figure 5 Applying for a claim IT VES Manual Practice Guide to Online Claiming

33 Applications for contact lenses that require the invoice to be attached cannot be applied for online (these include codes 13 & 14) Frames & lenses requiring prior approval cannot be applied for online Once completed, click the button. If the application is successful, a message will appear containing the claim number. This application does not require validating. If the application is not successful, an advisory message will appear. Figure 5.1 Applying for a claim 5 Validate a claim page When a patient has already made an online application, click on Validate a Claim on the menu bar, to validate the patient s card and details and to associate the claim with the practice the patient is attending. A claim number and matching surname must be entered. By clicking the Load claim button, the VES records are checked for the claim number. If the claim number is on record but linked to a different surname, an advisory message will appear and the validation process will not proceed. IT VES Manual Practice Guide to Online Claiming

34 If the claim number is on record with a matching surname, the details of the patient will be displayed. As with the Application process, please check that the card is current and that the card details match the patient. Having done this, clicking this tick box labelled Card is currently valid. This tick box indicates the practice s declaration that the card is valid. If the address and other patient details need to be changed, please enter the correct details. Click the button to save the details and associate the claim with your practice. 6 Claims to submit page Click on Claims to Submit on the menu bar, to access a list of the practice s claims, which have not yet been submitted but have been validated (see Figure 6). This is the fastest way to load a claim that is ready to be submitted. Claims are sorted alphabetically by last name. Click the button next to the claim to begin the submission process. This will load the Submit Claim page with the claim details loaded (see Figure 6). Click the claim is no longer required. button if Figure 6 List of claims ready awaiting submission 7 Submit a claim page Submitting a claim can be done in two ways: 1. By clicking the submit button after accessing the Claim to submit on the menu bar as outlined in Section 6. From this page, the claim details can be entered. 2. By clicking on Submit a claim on the menu bar. The claim number or patient s card number (see Figure 7) need to be entered. Then click the button. This page collects details on the claim items and queues the claim for payment by the VES. a. Select a practitioner from the list. If the correct practitioner is not listed, please contact the VES Office to update the practice and practitioner details. b. Ensure patients correct collection date is entered. (Patients will not be eligible until 2 years after the date of collection). c. Enter a valid combination of claim items. IT VES Manual Practice Guide to Online Claiming

35 d. Select any tints that apply in the second drop down window. The totals under the claim items display the Patient contribution, VES Subsidy and total sum. Once the details are correct, click the button. Assuming the details are valid, an advisory message will appear specifying that the claim was successfully submitted. Figure 7 Submitting a claim 8 Submitted claims page Click on Submitted Claims on the menu bar, to access a list of online claims submitted by the practice (see Figure 8). It includes the VES subsidy amount and a Paid column which will only be filled when the claim has been processed and paid by the VES Office. IT VES Manual Practice Guide to Online Claiming

36 Figure 8 List of submitted claims 9 Payment of claims The VES Office will run a program to process claims received and payments made to VES rural practices as set out by the VES Manual of Procedures and Conditions. If you require an updated copy of the manual please contact the VES Office. Payments will continue to occur electronically to the practice s nominated bank account. 10 Auditing The ACO may contact the VES practice from time to time to discuss a particular claim, claims pattern or complaint. Thank you letters are sent out to patients on a regular basis outlining the service they were provided and to contact VES office for any further assistance. IT VES Manual Practice Guide to Online Claiming

37 Appendix 14 - Victorian Aboriginal Spectacle Subsidy Scheme (VASSS) Background In 2009 the National Indigenous Eye Health Survey reported that blindness and vision impairment are 6.2 times and 2.8 times respectively more prevalent in adult Aboriginal Australians than in non-aboriginal Australians. Other findings were that 35% of adult Aboriginal people have never had an eye examination and 39% of adults cannot see normal print size. The main causes of vision loss in Aboriginal Australians are refractive error, presbyopia, cataract and diabetic eye disease; 94% of vision loss is preventable or treatable. Optometrists can play a key role in eliminating avoidable vision loss and affordable glasses are a key element. The Victorian Aboriginal Spectacle Subsidy Scheme (VASSS) is funded by the Victorian Government Department of Health and Human Services and provides affordable glasses to all Aboriginal and Torres Strait Islander community members who reside in Victoria. The subsidy is part of Koolin Balit, the Victorian Government strategy for Aboriginal Health, and is supported by the Victorian Eyecare Service. The VASSS is supported by the Koolin Balit Aboriginal Eye Health Advisory Group of the Department of Health and Human Services Victoria (formerly the Eye Health subcommittee of the Victorian Advisory Council on Koori Health) which includes representatives from the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), the peak body for the 24 Aboriginal Health Services across Victoria. The VASSS is available from participating VES practice partners in rural Victoria as well as all ACO services, including the Victorian Aboriginal Health Service (VAHS) in Fitzroy, Bunurong Aboriginal Health Service in Dandenong, The Gathering Place Health Service in Werribee, Carlton, Braybrook, East Preston, Berwick and Frankston, plus Outreach clinics in Melbourne and Visiting Optometrists Scheme services in regional Victoria. Under the scheme, participating optometrists bulk-bill consultations to Medicare so that patients pay no consultation fees i.e. the same arrangements as the VES. Patients make a contribution of $10 to the cost of their glasses and the VES/VASSS subsidy meets the balance of the cost. The ACO promotes participating VES practices as suppliers of the VASSS. VES practices are encouraged to display a sign in their practices indicating availability of the VASSS. Please contact the ACO if you would like to have a sign sent to your practice. Who is eligible for VASSS? Patients who identify as members of the Aboriginal and/or Torres Strait Islander communities and are residents of Victoria are eligible to access the VASSS. The ACO can assist setting up coordination of interested VES practices with their local Aboriginal Community Controlled Health Organisation (ACCHO) healthcare worker, school Aboriginal liaison officers, or other local Aboriginal healthcare workers associated with local hospitals, community or private health services. Aboriginal healthcare workers and liaison officers can organise referrals to the VES practice, confirming patients eligibility for the subsidy. The patient s GP may also provide a referral confirming eligibility and the Department of Health and Human Services advises that patients may also self identify as Aboriginal community members. The standard rules of the Victorian Eyecare Service apply to the VASSS, except that there is no requirement for Aboriginal and Torres Strait Islander patients to hold a Pensioner Concession or Health Care Card to obtain access to the subsidy. Contact lenses are available under the VASSS following VES rules. Low vision aids (low cost) may be available under the VASSS under certain circumstances if clinically necessary. Please contact the ACO if you believe a patient may require a low vision aid. September

38 How are VASSS claims made? The VES Practice completes a VES Group Application form on the patient s behalf for application to the VASSS and once approved, claim forms are sent directly to the practice. Please see the attached Group Application Claim Form or refer to the online claiming system. The patient makes a contribution towards the cost of their glasses. The VES office processes claims and arranges for payment as determined by the rules of the VASSS. The VES submits monthly reports of all payments made to the VES practice. What are the VASSS benefits? As with usual VES procedure, VASSS provides the assurance to patients that they will receive optometry care at a known, affordable cost so they will not be deterred from obtaining eye care because of uncertainty about expenses. Within a two-year period, the scheme includes: One pair of distance and one pair of reading glasses, or; One pair of bifocal glasses, or; One pair of multifocal glasses, where they are found to be clinically necessary. Tinted lenses and PGX can be provided if clinically necessary. Contact lenses can also be provided under VASSS if the VES criteria is met. All standard VES rules apply, with the key differences being eligibility (Aboriginal and/or Torres Strait Islander status rather than PCC/HCC status), expanded frame range, patient contribution amount, and combined practitioner payments made up of the VES scheduled fee (for lenses) and VASSS contribution (for frames). Low vision aids (low cost) may be available under certain circumstances if clinically necessary. Please contact the ACO if you believe a patient would benefit from a low vision aid. Patient contribution A standard patient contribution of $10.00 applies for all single vision, bifocals, multifocals and contact lenses found to be clinically necessary and in accordance with standard VES frame and lens rules. The patient may incur additional costs if they freely select a frame other than the standard VES or VASSS range frames, or lenses not eligible for subsidy under standard VES rules. As with VES rules, under no circumstances can the patient be pressured into purchasing non-standard items. VASSS contribution The VASSS contribution is an additional subsidy (compared with the VES scheduled fee for frames) placed on the purchase of all new frames, including VASSS approved frames, standard VES frames and non-standard frames. If no frame is purchased, then the VASSS contribution does not apply. Frame range Eligible patients have access to a new pre-approved frame range, supplied by Rimoptics. This is in addition to the standard VES plastic frames. The VASSS frame range has been endorsed by Elders from the Aboriginal communities. If a frame outside the approved range is required please contact the ACO. Participating practices should contact Rimoptics to arrange the VASSS range of frames for patient demonstration. A pre-negotiated rate is in place if required. Practices are permitted to use these frames September

39 for other patients, provided an agreed set is kept in the practice for VASSS eligible patients. Under no circumstances can practices substitute the range. It is suggested that practices display the frame range at a suitably accessible location in the practice so that Aboriginal and Torres Strait Islander patients feel comfortable with the process of selecting frames. Lens range Spectacle lenses and contact lenses included under the scheme are in accordance with standard VES rules. A surcharge applies for replacement of lost, damaged or broken glasses within two years, where there is no clinical necessity to change the lenses. Non-VES lenses may be provided (eg transitions or high index) at the request of patients and it is expected that a reasonable and appropriate commercial fee would be charged. The frame subsidy still applies provided a frame is purchased. We would appreciate it if out of pocket costs for patients are kept to a minimum to ensure affordability and availability of spectacles. ACO is happy to provide guidance as required. How much will the practice receive for a visual aid claim? When glasses or contact lenses are clinically necessary, the practice is paid the VES Scheduled fee for lenses (which includes the standard $10 patient contribution fee), plus the VASSS contribution for the frame. As the $10 contribution is paid directly by the patient, the VES will pay the total entitlement less the $10 patient contribution. The following flow chart demonstrates how a practice can calculate the total VES payment they will receive for any given claim. September