Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth

MassHealth
Vision Care Bulletin 16
February 2012

TO:	Vision Care Providers 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 Form
For MassHealth’s vision care contractor (MassCor) to comply with these 
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 Requests
Duplicate VIS-1 form submissions are unnecessary and hinder the
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 Materials Catalog
MassCor and MassHealth are pleased to announce that the available 
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.


MassHealth
THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services

Vision Care
Material Order Form

Mail this form to:
MassCor/Massachusetts Correctional Industries P.O. Box 466 Gardner, MA 01440

Homeless Person

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:
Last
First
MI
Date of Birth:
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
  single vision
  bifocal 
  lenticular aspheric
  Other (Non-contract material)
  rd seg
  sv
  fat top 28 (       )
  rd seg

COMPLETE IN MINUS CYLINDER

		SPH		CYL	AXIS	PRISMS		BASE	DECENTER	
DIST	R	 							IN   OUT								
RX	L									
			Segment Height  Inset    Total Inset    PD							
Add for near	R			R		R	Far	
		L			L		L	Near	
Color		
pink 1	C1 
pink 2	C2 
Other 	C3 
(See regulations at 130 CMR 402.000, accessible at www.mass.gov/masshealth.)		
		
Diagnosis Code		
367.0 - Hypermetropia	
367.1 – Myopia	
367.20 – Astigmatism	
367.4 – Presbyopia	

Date Shipped:
Date Received:
Special Instructions:

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 falsifcation, omission, or concealment of any material fact contained herein.

Signature:
Date:

Send original to MassCor. Keep a copy for your records.

VIS-1 (Rev. 01/12)