Paper Orders

Most VSP doctors use Eyefinity to submit their orders electronically to a VSP contract lab; however, some still use the Materials Invoice form and a CMS-1500 form.  These forms serve several functions.  They act as lab order forms, patient coverage documentation, and claim forms that VSP uses to process payment to doctors and labs.

Doctors use the VSP Materials Invoice form in conjunction with the CMS-1500 form to place an order if a patient is eligible for, and the doctor dispenses, lenses and/or frames. 


  1. On paper orders, verify that the CMS-1500 form is included in the documentation.  If it is not, do not complete the order.  Return all paperwork to the doctor and request a completed CMS-1500 form.  This form is required to receive payment from VSP.
  2. Write the date that you received the Materials Invoice under "Arrival Date.”   
  3. Enter your VSP contract laboratory number in the "Lab ID Code" area.
  4. Provide the materials requested and list the appropriate option codes in the "Option Codes" area.  For a list of applicable lens and options codes, please refer to the Product Index.
  5. When the order is complete and ready for shipment, indicate the "Mailing Date.”
  6. Detach the canary (lab) copy and keep it for your records.
  7. Detach the pink (doctor) copy and send it to the doctor with the completed order.
  8. Send the white (VSP) copy to VSP with the CMS-1500 form attached for payment.

It is the doctor's responsibility to verify a patient's coverage.  It is important that any materials dispensed (lenses, frames and/or options) are listed with their appropriate code(s) on the CMS-1500 form.  Information provided on the Materials Invoice is for lab use only.  VSP will reimburse only for services listed on the CMS-1500 form.

Contract laboratories are not responsible for screening order forms for eligibility information; however, you may find the following information helpful in understanding these forms.  Correctly interpreting order forms helps expedite payment.

Patient Information

  1. The order form provides identification information about the patient and the patient’s group and plan.  This information is useful when communicating with VSP about a particular order.

    Patient identification includes:

  2. Patient’s name
  3. Patient’s date of birth
  4. Relationship of patient to member
  5. Member’s identification number (usually the member’s social security number)
  6. Member’s VSP group name
  7. Member’s name and address

Patient Coverage

The doctor enters the services the patient is eligible to and the expiration date of the order form as instructed by VSP.  The word YES will be circled in the boxes for those services for which the patient is currently eligible.  If a date appears in one of the service boxes, this means the patient will be eligible for that service on or after that date.

VSP allows payment for services performed on or after the 15th of the month prior to the eligibility date, as long as the patient was eligible for at least one service.  (Example: Patient with an exam exclusion of 3/2010 may receive services on or after 2/15/2010).

Order Details

Comment Codes

Comment Codes are assigned when there are special instructions regarding the patient’s benefits.  In some cases, multiple codes may apply.  Labs need only be concerned with those beginning with the letter "L." Please see Quick Links in Additional Info and click on 'Lab Comment Codes (Excel Spreadsheet)'.

Benefit Type

There are many VSP Benefit Types.  Consult the section on VSP Plans for additional information.

Doctor Identification

Doctors are responsible for entering their identification number on the order form.  If it is not listed, contact the doctor’s office.

Date of Service

The doctor is required to list the Date of Service.

Authorization Number

Verify that this field has been completed by the doctor.  If it is not on the form, contact the doctor’s office.

Lab ID

If your laboratory’s I.D. number is not included on the order form, VSP will have no way of knowing which laboratory provided services.  Please ensure that this number is legible.

Invoice Number

Your invoice number is a way for you to identify an order internally.  In the Invoice Number box, insert your own invoice number (which must be between 1 and 8 digits long).  If the invoice number box is blank or illegible, "00000001" will used as an invoice number for that order.  Do not use letters in your invoice number.


Please enter the date the order arrived at your laboratory in the Arrival Date box and the date it was mailed to the doctor in the Mailing Date box.

Lens Enhancement Codes

If the doctor orders lens enhancements, write the appropriate lens enhancement codes in the Lens Enhancement Codes boxes (Lab Use Only boxes).  Refer to the Product Index for the appropriate lens enhancement codes.

In some cases, the doctor may provide a dye or UV protection in his or her in-office laboratory.  In these cases, the doctor will write the correct in-office lens enhancement code in the Lens Enhancement Code boxes.  For more information, see Doctor In-Office Lens Enhancements.

VSP will pay your laboratory for lens enhancements ordered on the order form by the codes your laboratory indicates.  If a lens enhancement code is not included on the order form, it will not be paid to your laboratory.  If you make changes per the doctor's request, make sure to highlight them on the order form before sending the forms to VSP and the doctor.

Coordination of Benefits

Some groups allow their members to Coordinate Benefits.  In these cases, you will receive two forms for the same patient with only one form having completed prescription information.  The VSP COB Form Number box, located in the Professional Services section of the form contains the authorization number of the secondary form.  The forms should be clearly marked "coordination of benefits" or "COB" by the doctor.  If there is any question, contact the doctor’s office for clarification.  So that orders are processed correctly, VSP must receive both order forms at the same time.  Please staple the forms together when submitting for payment.


If the doctor requests a lab-supplied frame, enter the wholesale cost of the frame in the Frame Cost box in the Frame Service area under the Prescription/Material Information section.  The Frame Service section should be marked by the doctor to indicate a lab-supplied frame.

Other Forms

Some VSP plans require special forms.  Please attach these to the Material Invoice form (white copy) when sending them to VSP.  These forms are:

  • Pre-Certification form
  • Post-Authorization form
  • Interim Benefits form

Submission to VSP

Submit the VSP Copy (white) directly to VSP once materials are completed and returned to the doctor.  VSP will process the order manually and pay you and the doctor for services.  Be sure to retain the Lab Copy (canary) of the order form for your records.

Submit orders daily to ensure timely payment.

For In-Network Claims mail your forms to:

P O Box 495907
Cincinnati, OH 45249-5907

For Out-of-Network Claims mail your forms to:

P O Box 495918
Cincinnati, OH 45249-5918