Currentblue cross blue shield - michiganPolicy N/A

Determination of Refractive State

This policy governs coverage and reimbursement for determination of refractive state (refraction) services for BCN Advantage Medicare Advantage members, including eligible providers, billing, and member cost sharing.

Policy Summary

Payerblue cross blue shield - michigan

PolicyDetermination of Refractive State

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and applicable cost-share via the provider portal or by phone before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

92015CPT code defined for service

No restrictionsPayment limits

MD/DO/Ophthalmologist/OptometristEligible providers

AppliesMember cost share

BCN Advantage Coverage Criteria

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Service definition: Determination of refractive state (CPT 92015).

ALL of the following

Providers eligible to bill: M.D., D.O., Ophthalmologist, Optometrist.

ALL of the following

Payable locations: No restrictions.
Frequency limits: No restrictions.
Diagnosis restrictions: No restrictions.
Age restrictions: No restrictions.

ALL of the following

BCN Advantage determines benefit scope, reimbursement methodology, maximum allowable payment amounts and member cost sharing for this enhanced benefit (Original Medicare does not cover determination of refractive state).
Payment method: Provider is paid the lesser of the BCN allowed amount or the provider's charge, minus member cost share.
Member responsibility: Providers should collect applicable cost sharing from the member at the time of service when possible; members are responsible only for applicable copay/coinsurance/deductible and providers may not balance-bill beyond member cost share.

Service Codes and Payment Rules

Refractive state service codesCPTCovered

92015

Determination of refractive state

Payment rule

Payment methodologyProvider will be paid the lesser of the BCN allowed amount (see BCN Fee Schedules on Availity Essentials) or the provider's charge, minus the member's cost share.

Where to find allowed amountsAvaility Essentials → Secure Provider Resources → BCN Fee Schedules under the Fee Schedules tab.

Provider billing restrictionThis payment represents payment in full; providers are not allowed to bill the member for the difference between the allowed amount and the provider charge.

Member cost sharingMember's applicable cost share (copay/coinsurance/deductible) is subtracted from payment and is the member's responsibility to pay.

Billing, Verification, and Provider Requirements

Billing Rule

Billing and payment rules — verify benefits, collect only plan cost share, do not balance-bill

Verify member benefits and applicable cost sharing before providing service; collect only the appropriate BCN Advantage cost share (copay, coinsurance, or deductible) at time of service when possible. Providers must not balance-bill members for the difference between BCN's allowed amount and the provider's charge; payment is the lesser of the BCN allowed amount or provider charge minus the member's cost share. To find BCN Advantage plan maximum payment amounts, use the Availity Essentials provider portal (BCN Fee Schedules) or call BCN to verify benefits and cost-share at 1-866-309-1719.

Collect only the appropriate BCN Advantage cost sharing; do not collect more than the plan’s cost share.
Do not balance-bill members — payment is in full when BCN allowed amount (or provider charge if lesser) minus member cost share is paid.
Find BCN fee schedule allowed amounts via Availity Essentials → Secure Provider Resources → BCN Fee Schedules.
Verify benefits and cost share via provider portal or by calling 1-866-309-1719.

Key Definitions

Determination of refractive state

Definition of serviceDetermination of the refractive state is necessary for obtaining glasses and includes specification of lens type (monofocal, bifocal, other).

Lens parameters specifiedLens power, axis, prism, absorptive factor, impact resistance and other factors necessary for obtaining glasses.

PurposePerformed to determine the optical prescription and characteristics required for corrective lenses (glasses).

Policy Summary

Payerblue cross blue shield - michigan

PolicyDetermination of Refractive State

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and applicable cost-share via the provider portal or by phone before billing.

SourceLink

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