Neighborhood Health Plan RI vision coverage update

Coverage Criteria

Adult coverage (Medicaid)

Coverage for adults (Medicaid, 21+):

Adults (21+): Routine Eye Exam covered once every two (2) rolling years

As of the day a member turns age 21, the 2-year interval is calculated from the member's last claim(s) for exam and eyeglasses.

Adults (21+): Diabetic Eye Exams covered as medically necessary

Adults (21+): Eyeglasses - frames covered once every two (2) rolling years; lenses covered as medically necessary

Adults (21+): Contact lenses may be selected in lieu of eyeglasses when medical necessity indicates better management of the member's visual or ocular condition

Adults (21+): Other medically necessary treatment for illness or injury to the eye is covered

Pediatric coverage (Medicaid)

Coverage for children (Medicaid, under 21):

Children (<21): Eye exams covered as medically necessary

Children (<21): Eyeglasses and contact lenses covered

Children (<21) - Lenses: Lenses covered as medically necessary

Children (<21) - Frames: Documentation of need for a second pair must be in the patient record and may be required for any frames submitted after the first pair within a 12-month period

Replacement pair must duplicate the initial pair unless documentation cites reason for discrepancies.

INTEGRITY

INTEGRITY plan coverage highlights:

INTEGRITY: Routine Eye Exams covered once every two (2) rolling years

INTEGRITY: Diabetic Eye Exams covered once every one (1) rolling year

INTEGRITY: Eyeglasses - frames covered once every two (2) rolling years; lenses covered as medically necessary

INTEGRITY: Members may select one pair of contact lenses in lieu of eyeglasses if medically necessary

INTEGRITY: Post-cataract eyeglasses (frames and lenses) or contact lenses covered after each cataract surgery when an intraocular lens is inserted

Commercial (including SHOP) coverage

Commercial and SHOP coverage summaries:

Commercial adults (19+): Routine Eye Exams covered once per plan year

Eyeglasses (frames and lenses) and contact lenses coverage applies to SHOP plans only; for SHOP, member pays provider and Neighborhood reimburses up to $150 once per plan year.

Commercial children (<19): Routine Eye Exams covered once per plan year

Comprehensive low vision evaluation once every five plan years; low vision follow-ups four times every five plan years; low vision aid devices reimbursed up to $600 per device when medically necessary; reimbursement allowed for only one of either eyeglasses or contact lenses per plan year.

Commercial - Diabetic and other medical care: Diabetic Eye Exams and other medically necessary treatment for illness or injury to the eye are covered as medically necessary

Not covered / Exclusions

Coverage exclusions (explicit):

Exclusions: Refraction services not separately reimbursable when billed with a routine or medical eye exam or an E/M service

Exclusions: Fitting of eyeglasses (unless billed with new frames and/or lenses) is not reimbursable

Exclusions: Repair and refitting of eyeglasses not separately reimbursable

Exclusions: Replacement of lost or stolen eyewear is non-covered for Medicaid adults, Commercial and INTEGRITY members

Exclusions:

Refraction services and fittings have specific reimbursement limitations. Refraction services are not separately reimbursable when billed with a routine or medical eye exam or an E/M service. In addition, fitting of eyeglasses (unless billed with new frames and/or lenses) and repair/refitting of eyeglasses are not separately reimbursable. Providers should not bill separate refraction or fitting fees when these services are included in the covered exam or when billed with an evaluation and management code.

This payment policy is provided for informational purposes to describe Neighborhood Health Plan of Rhode Island’s coverage and reimbursement approach for vision services. It is not a guarantee of reimbursement; actual payment is determined at claim adjudication and remains subject to benefit coverage, member eligibility, coding and documentation requirements, authorization policies, provider contract terms, and applicable state and federal regulations.

The policy content is intended to guide billing and clinical operations but may not cover every possible scenario. Neighborhood may update or interpret the policy differently across electronic claims processing systems due to programming or other constraints. Providers should verify eligibility, coverage, and any authorization requirements prior to providing services.

Replacement of lost or stolen eyewear is non‑covered for Medicaid adults, Commercial, and INTEGRITY members. Claims submitted for replacement of eyewear due to loss or theft for these member groups will be denied under this policy’s exclusions.

Coding and Billing Codes

Routine Vision Exam CodesICD-10Covered

Z01.00	Encounter for examination of eyes and vision without abnormal findings
Z01.01	Encounter for examination of eyes and vision with abnormal findings
S0620	Routine ophthalmological examination including refraction; new patient
S0621	Routine ophthalmological examination including refraction; established patient

Diabetic Eye Exam Diagnosis RangesICD-10Covered

E08.00-E08.29	Diabetes mellitus due to underlying condition, with various manifestations (range for eye-related codes)
E08.40-E09.29	Diabetes with ophthalmic manifestations ranges (included per policy)
E09.40-E10.29	Diabetes due to other specified causes to type 1 diabetes ophthalmic ranges
E10.40-E11.29	Type 1 and Type 2 diabetes ophthalmic ranges
E11.40-E13.29	Type 2 to other specified diabetes ophthalmic ranges
E13.40-E13.9	Other specified diabetes mellitus with ophthalmic manifestations to unspecified

Medically Necessary Diagnosis Ranges and CodesICD-10Covered

A18.50-A74.0	Selected infectious/parasitic disease codes range (includes A18.50-A18.59 and up through A74.0 as applicable)
B00.50-B60.13	Selected viral/other infectious disease code ranges (includes B00.50-B00.59, B02.32-B02.39, B30.0-B30.9, B39.4-B39.9, B58.01-B58.09, B60.12-B60.13 as applicable)
A50.31	Specific congenital or infectious condition (included in medically necessary list)
A51.43	Specific listed sexually transmitted infection manifestation (included)
A54.30-A54.39	Gonococcal infection range (included)
A71.0-A74.0	Additional specified infectious disease range (included)
A74.89	Other specified chlamydial disease (included)
B02.32	Zoster with ocular complications (included)
B02.33	Zoster with other specified complications (included)
B02.39	Zoster with unspecified complications (included)

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Table 2: Selected Ophthalmology CPT/ICD Codes (Clinical & E/M)mixedCovered

92002	Ophthalmological services: medical examination and evaluation; 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
99201	Office/outpatient visit, new patient, problem focused (typically 10 minutes)
99202	Office/outpatient visit, new patient, expanded problem focused (typically 20 minutes)
99203	Office/outpatient visit, new patient, detailed (typically 30 minutes)
99204	Office/outpatient visit, new patient, comprehensive (typically 45 minutes)
99205	Office/outpatient visit, new patient, high complexity (typically 60 minutes)

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Table 3: All Other Vision Services (CPT/HCPCS)mixedCovered

65765	Keratophakia
66710	Ciliary body destruction; cyclophotocoagulation, transscleral
66761	Iridotomy/iridectomy by laser surgery
66762	Iridoplasty by photocoagulation
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 interpretation and report
92065	Orthoptic and/or pleoptic training

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All Other Vision Services Continued (CPT/HCPCS)mixedCovered

92270	Electro-oculography with interpretation and report
92273	Electroretinography (full field) with interpretation and report
92274	Electroretinography (multifocal) with interpretation and report
92283	Color vision exam, extended
92284	Dark adaptation exam with interpretation and report
92285	External ocular photography for documentation of medical progress
92286	Anterior segment imaging with specular microscopy and endothelial cell analysis
92287	Anterior segment imaging with fluorescein angiography
92310	Prescription and fitting of contact lens, corneal lens, both eyes
92311	Prescription and fitting of contact lens, corneal lens for aphakia, 1 eye

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All Other Vision Services Lenses, Supplies, HCPCS V-codesHCPCSCovered

92341	Fitting of spectacles; bifocal
92342	Fitting of spectacles; multifocal
92352	Fitting of spectacle prosthesis for aphakia; monofocal
92353	Fitting of spectacle prosthesis for aphakia; multifocal
92354	Fitting of spectacle mounted low vision aid; single element
92355	Fitting of spectacle mounted low vision aid; telescopic or compound lens
92358	Prosthesis service for aphakia, temporary
C1840	Lens, intraocular (telescopic)
S0515	Scleral lens, liquid bandage device, per lens
S0580	Polycarbonate lens (list in addition to basic code)

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Provider Actions and Requirements

Prior Authorization

Verify authorization before services

Verify member eligibility, benefits, and prior authorization requirements before rendering services. It is the provider's responsibility to confirm authorization and that services are medically necessary per Neighborhood criteria (NCD, LCD, InterQual, EOHHS recommendations, Clinical Medical Policies). Contact Provider Services at 1-800-963-1001 or refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for plan-specific requirements.

Verify authorization and member eligibility prior to services
Check plan-specific prior authorization reference for requirements
Contact Provider Services for authorization questions

Prior Authorization

Prior authorization (as applicable)

Background

Vision care encompasses routine and medical eye examinations as well as corrective hardware such as frames, lenses, and contact lenses. This policy outlines coverage, reimbursement, and documentation requirements across lines of business and lists specific exclusions. Examples of explicit exclusions include separate reimbursement for refractions billed with an exam or E/M service, nonprescription lenses, polycarbonate lenses for adults (age 21+), two pairs in lieu of bifocals, contact lens insurance, prescription sunglasses, and LASIK surgery. Because the policy is informational, claim payment determinations remain subject to member eligibility, coding and documentation guidelines, authorization rules, provider contract terms, and state and federal regulations; all billed services are subject to audit.

Definitions

inv-32: Routine Eye Exam

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

Typical componentsVisual acuity, refraction, ocular motility, external and internal eye inspection, basic screening for eye disease.

PurposeScreening and detection of refractive errors and common ocular diseases to determine need for corrective lenses or further evaluation.

inv-33: 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 for specialized diagnostic or treatment services.

IncludesOrdering/arranging consultations, laboratory or radiologic studies, and initiating treatment or referrals as indicated.

OpenPayer

Vision Care Services — Coverage and Reimbursement

Coverage Criteria

Coding and Billing Codes

Provider Actions and Requirements

Background

Definitions