Utilization Management Policy for Vision Services
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Governs authorization and administration of vision benefits (lenses, contact lenses, frames, and certain eye-related services) for Astiva Health members, primarily describing Medicare applicability and referral/coverage processes.
No material clinical or coverage changes in this revision.
Coverage Criteria — Vision Services
Covered services
Covered vision services and conditions
Benefit cannot be reserved from one surgery to use after a second separate surgery.
Classified as Routine/Non-Medicare Covered where applicable.
Services lacking a required written prescription may be denied.
Original Medicare does not cover routine eye exams (eye refractions) for eyeglasses or contact lenses. Routine vision benefits, including eyewear allowances from a network provider, are considered plan-level benefits and may be subject to the member’s Plan Evidence of Coverage and any plan-specified limits or allowances.
Routine eye refractions for the purpose of prescribing eyeglasses or contact lenses are not covered by Original Medicare. When members seek optical eyewear, coverage and any allowances (for example, one pair of glasses or contact lenses every two years from a network provider) are administered according to plan rules and the member’s Evidence of Coverage.
Provider Actions, Authorization & Documentation
Prior authorization and referral — self-referral allowed; eyewear requires prescription
Members may self-refer for annual routine vision services and may schedule an appointment with a contracted optical provider without prior authorization. Optical eyewear remains a covered benefit when provided with the required written prescription by a contracting physician, optometrist, or ophthalmologist.
- Self-referral permitted for annual routine vision services.
- No prior authorization required to schedule with a contracted optical provider.
- Optical eyewear coverage requires a written prescription (see Prescription requirement).
Provider role — educate and refer during routine visits
Primary care providers (Health Plan/IPA PCPs) should use well visits and routine exams to educate members about vision care and to make corrective and preventive referrals when indicated.
- Encourage vision care awareness during Well Visit exams.
- Make corrective and preventive referrals to eye care providers as appropriate.
Prescription requirement for optical eyewear
Optical eyewear (lenses, contact lenses, frames) is a covered benefit only when there is a written prescription from a contracting physician, optometrist, or ophthalmologist.
- Ensure a written prescription from a contracting physician, optometrist, or ophthalmologist is obtained and retained for eyewear orders.
- Confirm provider is in the contracting network before relying on benefit coverage.
Denial triggers — missing prescription or out-of-benefit services
Claims or services may be denied if there is no written prescription from a contracting physician, optometrist, or ophthalmologist, or if services fall outside covered benefit limits (for example, more frequent eyewear than plan-specified allowances).
- Missing written prescription from a contracting provider is a denial trigger.
- Requests exceeding benefit frequency or allowance (e.g., more than one eyewear allowance within the specified period) may be denied.
- Routine eye refractions for eyeglasses/contacts are not covered by Original Medicare and may be denied under Medicare rules.
Background
Medicare covers outpatient physician services for the diagnosis and treatment of eye diseases and injuries, including disease-related preventive services such as annual glaucoma screening for people at high risk and annual diabetic retinopathy screening for people with diabetes. In contrast, routine refractive services to determine prescriptions for eyeglasses or contact lenses are not covered by Original Medicare. Plan-level routine vision benefits (for example, an eyewear allowance after cataract surgery or periodic eyewear allowances from a network provider) are governed by the member’s plan Evidence of Coverage and may require a prescription from a contracting eye care provider.
Definitions
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