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  • Davis Vision Ancillary Servicesrequest Form

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ANCILLARY SERVICES AUTHORIZATION REQUEST Check one of the following DME Home Care Services Fax To 877-431-8859 PT/OT/ST Transition of Care Required Information All required fields on this form must be completed. Please type or print in black ink and submit this request to the fax number above.

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Contact support

HCPCS Code for Contact lens, other type V2599.

In addition to the basic eye examination, a contact lens fitting is reimbursable with CPT® codes 92071, 92072 and 92310 thru 92312 for recipients with medically necessary conditions.

CPT 92002, 92004, 92012, 92014, 92015, S0620, and S0621 are reported per patient and not per eye. These procedures are considered to be unilateral or bilateral and may only be reimbursed once per encounter.

Members and dependents may receive up to 3 pairs of glasses, or 1 supply of contact lenses and 2 pairs of glasses.

HCPCS code V2500 for Contact lens, PMMA, spherical, per lens as maintained by CMS falls under Assorted Contact Lenses .

92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232