ENV 1
3 OF 3
VisionCare Plan
A CompBenefits Company
1511 N. Westshore Blvd.
Tampa, FL 33607
P9894028006
WHITE STOCK
Provider
Provider
Provider
Provider
Name
Address Information
Address Information
Address Information
200711290282 TE
Forwarding Service Requested
A
Customer Service
For VCP call (800) 865-3676
Check Number:
Check Date:
Appeals or Requested information must be received within 60
days from the date of the Explanation of Payment
Group
Vision Pass
Number
Patient Name
Remark
Code
Exam
Lenses
Frames
Contact
Lens
Patient
Co-pay
Other
Net Paid
Total This Check:
Message Codes and Descriptions
B
A
B
Provider Information
Section A indicates voucher information.
* Check Number
* Check Date
Description of Service Provided and Amounts Payable by Plan.
Section C includes the information that the provider receives about the Vision Pass Numbers.
Group: Member's group.
Vision Pass Number: Unique identification of vision services.
Patient Name: Patient's name.
Remark Code: Ineligible code and description. A message is given for the service being considered.
Patient Co-pay: Amount of co-pay paid by patient.
Other: Other amounts to be considered for Vision Pass Number.
Net Paid: Amount payable by the plan after provider discounts, total patient costs (copays and deductibles) amounts have been applied.