CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vision Care Services Payment Policy

Defines coverage and reimbursement requirements, medical necessity criteria, billing, documentation, and code lists for routine and medically necessary vision care services, eyeglasses, contact lenses, low vision services for Medicaid, INTEGRITY and Commercial members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision Care Services Payment Policy

Policy CodePolicy N/A

Change TypeRevisions & documentation updates (most recent 03/01/2022)

Effective DateJul 1, 2011

Next Review Date

Key ActionVerify eligibility, coverage and prior authorization criteria before rendering services and submit complete claims with required documentation (including specific documentation for frames, replacements, and pickups).

SourceLink

POLICY UPDATE CHANGES

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

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

09/29/2021 Action = Policy Review/Revisions: Combine Vision & Ophthalmology Policies, Format update, Update language for refractions, eyeglass fitting, repairs, Coding updates, Documentation requirements updates.

09/01/2013 Action = Policy Review/Revisions: Format change, added rendering provider language, added date of service language, added supportive diagnosis and coding guideline language.

07/01/2011 Action = Original Policy Effective Date

ExtensiveCovered Procedure Codes

MultipleDiagnosis Code Ranges Listed

1/yr or 1/2yrsExam Frequency Rules

Policy Overview

This policy (payer: Neighborhood) governs coverage and reimbursement for vision care services — including routine and medical eye exams, surgeries related to the eye and ocular adnexa, and vision hardware (frames, lenses, contact lenses). It applies to Medicaid (excluding EFP), INTEGRITY, and Commercial plans (including SHOP), and notes that plan-specific frequency and reimbursement rules apply (for example, routine exam and eyeglass frequency differ between Medicaid/INTEGRITY and Commercial/SHOP), so providers must verify member-specific coverage and payment terms.

Document-level Key Facts

Effective Date2011-07-01

Last Review2022-03-01

Next Review

Coverage Stancemixed

Scope SummaryDefines coverage and reimbursement requirements, medical necessity criteria, billing, documentation, and code lists for routine and medically necessary vision care services, eyeglasses, contact lenses, low vision services for Medicaid, INTEGRITY and Commercial members.

Routine Eye Exam Frequency (summary)Adults (Medicaid/General): once every 2 rolling years; Adults (Commercial SHOP): once per plan year; Children (Commercial SHOP): once per plan year

Low Vision Aid CapLow vision aid devices reimbursed up to $600 per device

Coverage & Medical Necessity

Billing & Documentation Requirements

Billing Rule

Refraction billing rule

Refraction services are not separately reimbursable when billed with a routine or medical eye exam or an evaluation and management (E/M) service.

Affected codes: refraction not separately paid when paired with S0620 or S0621 (Table 1)
Affected codes: refraction not separately paid when paired with 92002 or 92004 (Table 2)
Affected codes: refraction not separately paid when paired with appropriate E/M codes (99201-99205, 99211-99215)

Billing Rule

Eyeglass fitting billing rule

Fitting of eyeglasses is not reimbursable unless billed with new frames and/or lenses.

Documentation & Provider Requirements

Documentation Required

Frames after second pair - medical records required

Medical records are required for all frames submitted after the second pair rendered to the same patient within a 12-month period.

Applies when second pair rendered within 12 months

Documentation Required

Replacement frames/lenses documentation

Medical record documentation for replacement frames or lenses must include the reason for the replacement.

Document the clinical or other reason prompting replacement

Code Lists

Routine Vision Exam CodesHCPCSCovered

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

Ophthalmological/Medical Eye Exam Codes (Table 2)CPTCovered

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

E/M Codes for Medically Necessary Eye ExamsCPTCovered

99201	Office/outpatient visit new patient, problem focused
99202	Office/outpatient visit new patient, expanded problem focused
99203	Office/outpatient visit new patient, detailed
99204	Office/outpatient visit new patient, comprehensive
99205	Office/outpatient visit new patient, high complexity
99211	Office/outpatient visit established patient, minimal
99212	Office/outpatient visit established patient, problem focused
99213	Office/outpatient visit established patient, expanded problem focused
99214	Office/outpatient visit established patient, detailed
99215	Office/outpatient visit established patient, high complexity

All Other Vision ServicesmixedCovered

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
92060	Sensorimotor examination with multiple measurements
92065	Orthoptic and/or pleoptic training

1–10 of 165

1/17

Key Definitions

Definitions

Routine Eye ExamSeries of tests to evaluate vision and check for eye diseases.

Medical Vision Exams (Non-Routine)Examination and evaluation of a new or existing condition with initiation of a diagnostic and treatment program, including prescription of medication and arranging for specialty services, consultations, labs and radiology.

Frequency & Financial Thresholds

Thresholds

Routine Eye Exam - Adults (Medicaid/General)Once every 2 rolling years

Routine Eye Exam - Adults (Commercial SHOP)Once per plan year

Routine Eye Exam - Children (Commercial SHOP)Once per plan year

Diabetic Eye Exam FrequencyCovered as medically necessary (INTEGRITY: once every 1 rolling year)

Low Vision Evaluation FrequencyComprehensive low vision evaluation: once every 5 plan years (children commercial)

Low Vision Follow-up FrequencyLow vision follow up care visits: 4 visits every 5 plan years (children commercial)

Low Vision Aid Device Limit

Policy Revision History

2011-07-01original_effective

Original Policy Effective Date

2013-09-01review

Policy Review/Revisions: Format change, added rendering provider language, added date of service language, added supportive diagnosis and coding guideline language.

2021-09-29review_revisions

Policy Review/Revisions: Combine Vision & Ophthalmology Policies, format update, update language for refractions, eyeglass fitting, repairs, coding updates, documentation requirements updates.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision Care Services Payment Policy

Policy CodePolicy N/A

Change TypeRevisions & documentation updates (most recent 03/01/2022)

Effective DateJul 1, 2011

Next Review Date

SourceLink

On This Page

Billing Rule

Claims submission timeliness

Providers must submit complete claims within contractually determined timely filing guidelines. Adjustments, corrections, and reconsiderations must include required forms and comply with National Claims Standards.

Prior Authorization

Prior authorization / eligibility verification

Providers are responsible to verify eligibility, coverage and authorization criteria prior to rendering services. Refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for details; contact Provider Services for assistance.

Provider Services contact: 1-800-963-1001

Refraction services are not separately reimbursable when billed with a routine or medical eye exam or an E/M service; fitting is not reimbursable unless billed with new frames and/or lenses; and repair/refitting of eyeglasses is not separately reimbursable. Replacement of lost or stolen eyewear is non‑covered for Medicaid adults, Commercial and INTEGRITY members, while reimbursement and documentation rules for replacements, repairs, and multiple frame submissions differ by member group (for example, SHOP members pay the provider and are reimbursed per SHOP rules). Providers must follow documentation and timely filing requirements and verify eligibility prior to rendering services.

Documentation Required

Glasses pickup documentation

Medical records must include the pickup date for glasses and the signature and license number of the Optometrist or Optician who dispensed them.

Include pickup date and signature/license number of Optometrist or Optician

Note

Medical records and replacement requirements

Medical records are required for certain frame and second-pair claims; when reimbursing replacements, the replacement should duplicate the original prescription and frames where applicable.

Replacement should duplicate original prescription and frames when applicable

Reimbursed up to $600 per device

2022-01-24documentation_update

Documentation Requirements updated to include Optician.

2022-03-01effective_date_for_revisionsLatest

Effective date for revisions reviewed 09/29/2021.