CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vision care services payment policy

Defines coverage, reimbursement, billing and documentation requirements for vision care services (routine and medical eye exams, ophthalmologic services, surgeries, and vision hardware) for Neighborhood Health Plan of Rhode Island across Medicaid (excl EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision care services payment policy

Policy CodePolicy N/A

Change TypeRevisions; documentation updates

Effective DateMar 1, 2022

Next Review Date

Key ActionProviders must verify eligibility, coverage and authorization criteria prior to rendering services and ensure required documentation (including pickup date and Optometrist/Optician signature and license) is included when submitting claims.

POLICY UPDATE CHANGES

03/01/2022 Effective date for revisions reviewed 9/29.

01/24/2022 Update made to Documentation Requirements to include Optician.

09/29/2021 Policy review/revisions combining Vision & Ophthalmology Policies, format and coding updates.

MultipleHCPCS/CPT codes listed

Every 2 yrsAdult routine exam frequency (Medicaid/general)

1/yrPediatric routine exam frequency (Commercial/SHOP)

$600

Low vision aid device limit (children)

Policy overview and scope

Background: Payer payment policy governing vision care services for Neighborhood Health Plan of Rhode Island. It consolidates vision and ophthalmology coverage, listing covered CPT/HCPCS codes, billing rules, documentation requirements, frequency limits, and exclusions for routine and medical eye exams, surgical and diagnostic ophthalmology services, and vision hardware (frames, lenses, contact lenses).

Scope summary: Applies to Medicaid excluding Extended Family Planning (EFP), INTEGRITY, and Commercial lines. The policy governs coverage, reimbursement, billing and documentation requirements including frequency rules, coding/CPT/HCPCS pairing, required diagnosis codes, medical necessity criteria, documentation (including pickup date and Optometrist/Optician signature and license number), and specified exclusions (e.g., LASIK, prescription sunglasses).

Effective date: 2022-03-01. Last review: 2022-03-01.

Medical necessity & coverage criteria

General Medical Necessity

All services must be medically necessary to qualify for reimbursement. Neighborhood may use the following criteria to determine medical necessity:

NCD: National Coverage Determination (NCD) considered
LCD: Local Coverage Determination (LCD) considered
Interqual: Industry accepted criteria such as Interqual considered
EOHHS: Rhode Island Executive Office of Health and Human Services (EOHHS) recommendations considered
CMP: Neighborhood’s Clinical Medical Policies (CMP) considered

Routine Eye Exam — Adults (21+)

Coverage frequency and allowances for adults age 21 and older

Adults (21+) Routine & Related

Routine exam frequency: Routine Eye Exam covered once (1) every two (2) rolling years1 per 2 rolling years
Diabetic exam: Diabetic Eye Exams covered as medically necessary
Eyeglasses frequency: Eyeglasses (frames and lenses) covered once (1) every two (2) rolling years1 per 2 rolling years

Routine & Medical Vision — Children (under 21)

Coverage rules for members under age 21

Pediatric vision coverage

Eye exams: Eye Exams covered as medically necessary
Eyeglasses (frames and lenses) covered as medically necessary
Replacement of lost eyeglasses reimbursed as medically necessary; replacement should duplicate original prescription and frames
Repair or replacement parts: Repair or replacement of eyeglass parts reimbursed when damage not due to defective materials or workmanship; replacement should duplicate original prescription and frames

INTEGRITY Line — Frequency Rules

INTEGRITY-specific frequency rules

INTEGRITY frequency rules

Routine exam frequency: Routine Eye Exams covered once (1) every two (2) rolling years1 per 2 rolling years
Diabetic exam frequency: Diabetic Eye Exams covered once (1) every one (1) rolling year1 per year
Eyeglasses frequency: Eyeglasses (frames and lenses) are covered once (1) every two (2) rolling years1 per 2 rolling years

Commercial / SHOP Plans — Frequency Rules

Commercial plan frequency and SHOP-specific reimbursement notes

Commercial/SHOP frequency rules

Adults routine exam (SHOP): Adults (21+): Routine Eye Exams covered once (1) per plan year1 per plan year
Adults eyeglasses (SHOP): Adults (21+): Eyeglasses (frames and lenses) are covered once (1) per plan year (SHOP only); member pays provider and Neighborhood reimburses1 per plan year (SHOP)
Adults contacts (SHOP): Adults (21+): Contact Lenses are covered for one (1) prescription per plan year (SHOP only)1 per plan year (SHOP)

Coverage Exclusions

Services explicitly excluded from reimbursement

Refraction not reimbursable: Refraction services are not separately reimbursable when billed with a routine or medical eye exam or an evaluation and management service
Eyeglass fitting not reimbursable: Fitting of eyeglasses (unless billed with new frames and/or lenses) is not reimbursable
Repair/refitting not separately reimbursable: Repair and refitting of eyeglasses is not separately reimbursable
Replacement lost/stolen: Replacement of lost or stolen eyewear is non covered for Medicaid adults, Commercial and INTEGRITY members

Billing diagnosis & CPT/HCPCS pairing and coding rules

Billing Diagnosis & CPT/HCPCS Pairing Rules

Required diagnosis codes and service code tables for different exam types

Billing pairing rules

Routine Vision Exam pairing: Routine Vision Exam must be billed with diagnosis Z01.00 or Z01.01 and a code from Table 1 (S0620, S0621)Z01.00 or Z01.01 + Table 1
Diabetic Eye Exam pairing: Diabetic Eye Exams must be billed with diabetes-related diagnosis codes (E08.00–E13.9 ranges as listed) and a code from Table 2 (92002, 92004, 92012, 92014, 92015)Diabetes ICD ranges + Table 2
Medically necessary exam pairing:

Billing, documentation & prior authorization actions

Documentation Required

Medical necessity verification and documentation

Verify member eligibility, coverage, and medical necessity prior to rendering services. Providers should reference National Coverage Determinations (NCD), Local Coverage Determinations (LCD), Interqual, Rhode Island EOHHS recommendations, and Neighborhood Clinical Medical Policies (CMP) when determining medical necessity. Document verification in the patient record.

Prior Authorization

Prior Authorization Required — consult plan reference

Consult Neighborhood's plan-specific Prior Authorization Reference and relevant Clinical Medical Policies (CMP) to determine when prior authorization is required for vision services and vision hardware. Confirm authorization requirements and submit prior authorization requests per plan instructions before providing services that require approval.

See Neighborhood's Prior Authorization Reference page for plan-specific requirements

Documentation requirements (records & dispensing)

Documentation Requirements

Records and documentation required for reimbursement

Frames after second pair: Medical records required for all frames submitted after the second pair rendered to the same patient in a twelve (12) month periodAfter second pair in 12 months
Reason for replacement: Medical record documentation for replacement frames/lenses must include the reason for the replacement
Pickup date and signature: Medical record must include the pickup date for glasses as well as the signature and license number of the Optometrist or Optician dispensing them

Definitions & terminology

Authoritative sources referenced for determination of medical necessity include National Coverage Determination (NCD), Local Coverage Determination (LCD), industry-accepted criteria such as Interqual, Rhode Island EOHHS recommendations, and Neighborhood's Clinical Medical Policies (CMP). Providers are responsible for verifying eligibility, coverage and authorization criteria prior to rendering services and should refer to Neighborhood's Prior Authorization Reference page and CMPs.

Policy revision timeline

03/01/2022revision_effectiveLatest

Revision effective date referencing prior review 2021-09-29

01/24/2022documentation_requirement_added

Documentation requirement added Optician signature/license

09/29/2021policy_combination_and_updates

Combined policies and updates for refractions, fittings, repairs, coding, documentation

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision care services payment policy

Policy CodePolicy N/A

Change TypeRevisions; documentation updates

Effective DateMar 1, 2022

Next Review Date

On This Page

Contact lenses may be selected in lieu of eyeglasses if medical necessity indicates better management with contacts

Other medically necessary treatment for illness or injury to the eye is covered

Contacts in lieu: Members may select one (1) pair of contacts in lieu of eyeglasses if medically necessary

Post-cataract: Post cataract eyeglasses (frames and lenses) or contact lenses are covered after each cataract surgery when an intraocular lens is insertedper cataract surgery with IOL

Glaucoma screenings for high risk members are covered once (1) every one (1) rolling year1 per year for high risk

Other medically necessary treatment for illness or injury to the eye is covered

Children routine exam: Children (<21): Routine Eye Exams covered once (1) per plan year1 per plan year

Low vision evaluation: Children (<21): Comprehensive low vision evaluation covered once (1) every five (5) plan years1 per 5 plan years

Low vision follow up: Children (<21): Low vision follow up care visits covered four (4) times every five (5) plan years4 per 5 plan years

Low vision device limit: Children (<21): Low vision aid devices reimbursed up to $600 per device when medically necessaryUp to $600 per device

One of eyeglasses or contacts: Children (<21): Eyeglasses or Contact Lenses covered one (1) per plan year; reimbursement allowed for only one (1) of either eyeglasses or contact lenses per plan year1 device per plan year (either eyeglasses or contacts)

Nonprescription lenses are not covered

Polycarbonate adult lenses: Polycarbonate lenses for adults (age 21 years and older) are not covered

Two pairs in lieu of bifocals: Two (2) pairs of eyeglasses in lieu of bifocals are not covered

Contact lens insurance is not covered

Additional prescriptive eyewear for computer use, sports, and driving are not covered

Prescription sunglasses: Prescription Sunglasses are not covered

LASIK not covered: Lasik Surgery is not covered

Medically Necessary Eye Exams must be billed with one of the listed diagnosis codes (extensive list) and a code from Table 2 or appropriate E/M codes (92002/92004/92012/92014/92015 or 99201–99215 series)

Listed diagnosis codes + Table 2 or 99201-99215

All other vision services pairing: All Other Vision Services must be billed with one of the codes from Table 3 (extensive CPT/HCPCS list provided)Table 3 codes

Routine Vision Exam codesHCPCSCovered

S0620	Routine ophthalmological examination including refraction; new patient
S0621	Routine ophthalmological examination including refraction; established patient

Medical/Comprehensive Ophthalmological Exam codesCPTCovered

92002	Ophthalmological services: intermediate, new patient
92004	Ophthalmological services: comprehensive, new patient, 1 or more visits
92012	Ophthalmological services: intermediate, established patient
92014	Ophthalmological services: comprehensive, established patient, 1 or more visits
92015	Determination of refractive state

Evaluation & Management codes applicable to medically necessary eye examsCPTCovered

99201	Office/outpatient visit, new patient, problem focused; typically 10 minutes
99202	Office/outpatient visit, new patient; typically 20 minutes
99203	Office/outpatient visit, new patient; typically 30 minutes
99204	Office/outpatient visit, new patient; typically 45 minutes
99205	Office/outpatient visit, new patient; typically 60 minutes
99211	Office/outpatient visit, established patient; typically 5 minutes
99212	Office/outpatient visit, established patient; typically 10 minutes
99213	Office/outpatient visit, established patient; typically 15 minutes
99214	Office/outpatient visit, established patient; typically 25 minutes
99215	Office/outpatient visit, established patient; typically 40 minutes

All Other Vision Services (surgical, diagnostic, supplies, lenses, frames, contact lenses, low vision aids)mixedCovered

65765	Keratophakia
66710	Ciliary body destruction; cyclophotocoagulation, transscleral
66761	Iridotomy/iridectomy by laser surgery (per session)
66762	Iridoplasty by photocoagulation (1 or more sessions)
92018	Ophthalmological exam under general anesthesia; complete
92019	Ophthalmological exam under general anesthesia; limited
92020	Gonioscopy (separate procedure)
92025	Computerized corneal topography, with interpretation and report
92060	Sensorimotor examination with multiple measurements
92065	Orthoptic and/or pleoptic training

1–10 of 64

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Excluded procedures (not covered)procedureNot Covered

LASIK	Lasik Surgery (explicitly not covered)
Prescription Sunglasses	Prescription sunglasses (not covered)

Refer to applicable Clinical Medical Policies (CMP) for service-specific prior auth rules

Documentation Required

Documentation required after second pair within 12 months

Medical records are required for any frames submitted after the second pair rendered to the same patient within a 12‑month period. After the second pair in 12 months, include clinical justification and supporting documentation showing medical necessity for additional frames.

Applies to frames submitted after the second pair within a 12‑month period
Include clinical justification demonstrating medical necessity

Documentation Required

Replacement frames/lenses — document reason

For replacement frames or lenses, medical record documentation must state the reason for the replacement (for example: lost, stolen, damaged, change in medical condition, change in prescription) and demonstrate medical necessity when applicable.

Document specific reason for replacement in the medical record
If replacement is due to damage or loss, document circumstances and any prior repair attempts
Replacement that duplicates original prescription and frames should be noted when applicable

Documentation Required

Dispensing record requirement

Medical record must include the pickup date for glasses and the dispensing provider's signature. The dispensing Optometrist or Optician must sign the dispensing record and include their license number.

Include pickup date in the medical/dispensing record
Dispensing Optometrist/Optician signature required
Include Optometrist/Optician license number on the record

Billing Rule

Refraction billing restriction

Refraction services are not separately reimbursable when billed with a routine or medical eye exam (CPT/HCPCS vision exam codes) or an evaluation and management (E/M) service. Do not bill refraction separately in these situations.

Do not separately bill refraction when billed with routine/medical eye exam or E/M service

Billing Rule

Eyeglass fitting billing restriction

Fitting of eyeglasses is not reimbursable unless billed with new frames and/or lenses. Do not submit separate billing for fittings when no new frames or lenses are provided.

Fittings only reimbursable when billed with new frames and/or lenses

Billing Rule

Claim submission timeliness and coding standards

Submit complete claims within contractual timely filing guidelines. Claims must follow National Claims Standards and use accurate coding per CPT, ICD-10-CM, and HCPCS. Ensure adjustments, corrections, and reconsiderations include required forms and documentation.

Follow timely filing requirements per contract
Use CPT, ICD-10-CM, and HCPCS coding standards
Comply with National Claims Standards for submissions and resubmissions