Neighborhood Health Plan RI vision coverage update

Coverage and Medical Necessity Criteria

Coverage by member type and age

Coverage varies by member type and age. Covered services and frequency limits are shown below.

Adults (21 and older): Routine eye exam covered once every two (2) rolling years; eyeglasses (frames and lenses) covered once every two (2) rolling years; diabetic eye exams covered as medically necessary; contact lenses may be selected in lieu of eyeglasses if medical necessity indicates better management of the member's visual or ocular condition; other medically necessary treatment for illness or injury to the eye is covered.age >= 21

The two-year rolling interval is calculated from the member's last claim(s) for exam and eyeglasses.

Children (under 21): Eye exams and eyeglasses (frames and lenses) covered when medically necessary; reimbursement available for replacement of lost eyeglasses when medically necessary—replacement should duplicate the original prescription and frames; reimbursement available for repair or replacement of eyeglass parts when damage is not due to defective materials or workmanship.age < 21

See separate low-vision provisions for children (low vision eval and follow-up intervals, device reimbursement limits).

INTEGRITY (program-specific) allowances: Routine exams and eyeglasses (frames and lenses) covered once every two (2) years rolling; diabetic eye exams covered once every one (1) year rolling; members may select contacts in lieu of eyeglasses if medically necessary; glaucoma screening for high-risk members covered once every one (1) year rolling; post‑cataract eyeglasses or contact lenses covered after cataract surgery when an intraocular lens is inserted; other medically necessary treatment for illness or injury to the eye is covered.

Plan-year benefit variants: Some adult plans: routine eye exams and eyeglasses covered once per plan year; contact lenses covered one prescription per plan year. Children in some plans: routine eye exams covered once per plan year; comprehensive low vision evaluation covered once every five plan years; low vision follow-up covered up to four times every five plan years; low vision aid devices reimbursed up to $600 per device when medically necessary; only one of eyeglasses or contact lenses reimbursed per plan year.

Coverage exclusions

The following services are explicitly excluded from coverage.

Exclusions (summary): Refraction services are not separately reimbursable when billed with a routine or medical eye exam or an evaluation and management service; repair and refitting of eyeglasses not separately reimbursable; fitting of eyeglasses (unless billed with new frames and/or lenses) not reimbursable; replacement of lost or stolen eyewear is non‑covered for Medicaid adults, Commercial and INTEGRITY members; nonprescription lenses; polycarbonate lenses for adults (age 21 years and older); contact lens insurance; two pairs of eyeglasses in lieu of bifocals; additional prescriptive eyewear for computer use, sports, and driving; prescription sunglasses; LASIK surgery.

Medically Necessary Eye Exams

Medically necessary eye exams are those that meet the CPT E/M component requirements for the selected E/M code.

E/M visit component requirements: Visit meets the required components for the selected E/M code (history, examination, and medical decision making) and the typical time/complexity described for codes 99201–99205 (new patient) and 99211–99215 (established patient). Provider must document the components and time as appropriate.as per CPT descriptions

Select and bill the E/M code that reflects the documented history, exam, medical decision making, and time.

Replacement of lost or stolen eyewear, LASIK surgery, and nonprescription lenses are explicitly excluded under the policy. Additional exclusions include refraction services when billed with a routine or medical eye exam or an E/M service, repair and refitting of eyeglasses when billed separately, fitting of eyeglasses unless billed with new frames and/or lenses, polycarbonate lenses for adults age 21 and older, contact lens insurance, two pairs of eyeglasses in lieu of bifocals, additional prescriptive eyewear for computer use/sports/driving, and prescription sunglasses.

This policy is provided for informational purposes and is not a guarantee of reimbursement. Payment for services is subject to member benefit coverage, eligibility, claims-payment edit rules, documentation guidelines, authorization policies, provider contract terms, and applicable state and federal regulations; all services billed are subject to audit.

The following services are not covered per the Coverage Exclusions: LASIK surgery, nonprescription lenses, replacement of lost or stolen eyewear for Medicaid adults, Commercial and INTEGRITY members, polycarbonate lenses for adults (age ≥21), contact lens insurance, prescription sunglasses, additional prescriptive eyewear for specialized uses, refraction when billed with an exam/E&M, separate reimbursement for repair/refitting, and standalone fitting of eyeglasses (unless billed with new frames/lenses).

Billing Codes and Code Tables

Routine Vision ExammixedCovered

Z01.00	Routine vision exam diagnosis
Z01.01	Routine vision exam diagnosis
S0620	Routine ophthalmological examination including refraction; new patient
S0621	Routine ophthalmological examination including refraction; established patient

Diabetic and Medical Eye Exam Codes (Table 2)mixedCovered

E08.00 to E08.29	Diabetes mellitus with eye complications (range)
E09.40 to E10.29	Diabetes codes (as listed)
E10.40 to E11.29	Diabetes codes (as listed)
E11.40 to E13.29	Diabetes codes (as listed)
E13.40 to E13.9	Diabetes codes (as listed)
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

Medically Necessary Eye Exam Diagnoses and E/M CodesmixedCovered

A18.50 to A18.59	Specified infectious and parasitic diseases (range) listed for medically necessary exams
C69.00 to C69.92	Malignant neoplasm of eye (range)
H00.011 to H59.89	Diseases of the eye and adnexa (range)
92002	Ophthalmological services: intermediate new patient
99201	E/M new patient, problem focused, straightforward
99202	E/M new patient, expanded problem focused
99203	E/M new patient, detailed history/exam
99204	E/M new patient, comprehensive, moderate complexity
99205	E/M new patient, comprehensive, high complexity
99211	E/M established patient, minimal

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Exclusions - ProceduresCPTNot Covered

LASIK

LASIK surgery (listed as not covered)

Medically Necessary Eye Exams (E/M Codes)CPTCovered

99201	Office or other outpatient visit for the evaluation and management of a new patient; problem focused history/exam; straightforward MDM; typically 10 minutes.
99202	Office/outpatient visit new patient; expanded problem focused history/exam; straightforward MDM; typically 20 minutes.
99203	New patient; detailed history/exam; low complexity MDM; typically 30 minutes.
99204	New patient; comprehensive history/exam; moderate complexity MDM; typically 45 minutes.
99205	New patient; comprehensive history/exam; high complexity MDM; typically 60 minutes.
99211	Established patient visit; may not require physician presence; typically 5 minutes.
99212	Established patient; problem focused history/exam; straightforward MDM; typically 10 minutes.
99213	Established patient; expanded problem focused history/exam; low complexity MDM; typically 15 minutes.
99214	Established patient; detailed history/exam; moderate complexity MDM; typically 25 minutes.
99215	Established patient; comprehensive history/exam; high complexity MDM; typically 40 minutes.

All Other Vision Services (CPT/HCPCS/V codes)mixedCovered

65765	Keratophakia.
66710	Ciliary body destruction; cyclophotocoagulation, transscleral.
66761	Iridotomy/iridectomy by laser surgery (per session).
66762	Iridoplasty by photocoagulation (one 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 of ocular deviation with interpretation and report.
92065	Orthoptic and/or pleoptic training; with continuing medical direction and evaluation.

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Provider Responsibilities and Billing Guidance

Prior Authorization

Verify eligibility and prior authorization

Verify member eligibility, benefits, and any required prior authorization before scheduling or rendering services. Prior authorization requirements and clinical criteria may change; check Neighborhood Health Plan of Rhode Island's Prior Authorization Reference page and Clinical Medical Policies for current rules. Providers are responsible for confirming authorization status and obtaining any necessary approvals to avoid claim denials or payment delays.

Verify eligibility and benefits through the payer portal or clearinghouse.
Obtain prior authorization when required and document authorization number on the claim.
Contact Provider Services at 1-800-963-1001 for assistance.

Documentation Required

Frames / lenses documentation

Providers must maintain medical record documentation to support requests and claims for frames and lenses. Records must demonstrate medical necessity and include details required for replacement items.

Background and Scope

Vision care encompasses both routine vision services and medically necessary ophthalmology care, including diagnosis and treatment of eye diseases, surgical procedures, and vision hardware such as frames, lenses, and contact lenses. This policy defines which routine and medical eye exams, treatments, and vision hardware are covered and which are excluded, and it sets documentation and billing expectations. Providers should verify member eligibility and applicable benefit limits; note that some services (for example, replacements for lost/stolen eyewear and elective procedures such as LASIK) are excluded under the Coverage Exclusions, and payments remain subject to eligibility, authorization, documentation, and audit.

Key Terms and Definitions

inv-22: Routine Eye Exam definition

DefinitionA series of tests to evaluate vision and check for eye diseases.

Typical componentsVisual acuity, refraction, ocular health assessment (external exam, anterior segment), and screening for common eye diseases.

When usedRoutine screening and refractive assessment for asymptomatic patients or routine follow-up of stable vision.

Billing guidanceBill with routine vision exam diagnosis codes (e.g., Z01.00, Z01.01) and appropriate Table 1 codes per policy coding rules.

inv-23: Medical Vision Exam (Non-Routine)

DefinitionExamination and evaluation of a new or existing condition with initiation of a diagnostic and treatment program, including prescription of medication and arranging diagnostic or treatment services.

OpenPayer

Vision Care Services — Coverage and Medical Necessity (Ophthalmology/Optometry)

Coverage and Medical Necessity Criteria

Billing Codes and Code Tables

Provider Responsibilities and Billing Guidance

Background and Scope

Key Terms and Definitions