Neighborhood Health Plan RI vision coverage update

Coverage Criteria and Benefits

Benefit frequency and conditions

Coverage summaries by member type and age group.

Medicaid (general): Routine Eye Exam covered once every two (2) years (rolling). Diabetic Eye Exams covered as medically necessary. Eyeglass frames covered once every two (2) rolling years; lenses covered when 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. Replacement and repair of eyeglasses are permitted with documentation; replacements must duplicate the original prescription and frames unless documentation explains discrepancies.

From Medicaid section; see chunk 5.

INTEGRITY: Routine Eye Exams covered once every two (2) years (rolling). Eyeglass frames covered once every two (2) rolling years; lenses covered as medically necessary. Diabetic Eye Exams covered once every one (1) year (rolling). Members may select one contact lens in lieu of eyeglasses if medically necessary. Post‑cataract eyeglasses or contact lenses are covered after each cataract surgery when an intraocular lens is inserted. Glaucoma screening for high‑risk members covered once every one (1) rolling year.

From INTEGRITY section; see chunk 6.

Adults (19+): Routine Eye Exams covered once (1) per plan year. Eyeglasses (frames and lenses) covered once (1) per plan year. Contact lenses covered for one (1) prescription per plan year. Diabetic eye exams and other medically necessary treatment for illness or injury to the eye are covered per medical necessity. (SHOP plan reimbursement rules may apply as noted in the benefits section.)

From adult benefits; see chunk 7.

Children (<19): Routine Eye Exams covered once (1) per plan year. Comprehensive low vision evaluation covered once every five (5) plan years; low vision follow‑up care visits covered up to four (4) times every five (5) plan years. Eyeglasses (frames and lenses) covered once (1) per plan year. Low vision aid devices reimbursed up to $600 per device when medically necessary. Contact lenses covered for one (1) prescription per plan year. Reimbursement allowed for only one (1) of either eyeglasses or contact lenses per plan year. Documentation required for second frames or replacements as specified.

From children benefits; see chunk 8.

Billing criteria

Billing requirements for specific exam types.

Routine Vision Exam billing: Routine Vision Exams must be billed with an appropriate diagnosis (e.g., Z01.01) and a code from Table 1 (S0620 for new patients, S0621 for established patients).

See chunks 13-14.

Diabetic Eye Exam billing: Diabetic Eye Exams must be billed with an applicable diabetic diagnosis code (examples/ranges listed in the policy) and an appropriate code from Table 2 (e.g., 92002, 92004, 92012, 92014, 92015) or an applicable E/M code when clinically indicated.

See chunks 15,17-18.

Medically Necessary Ophthalmology/EM billing: Medically necessary ophthalmological exams must be billed with an appropriate diagnosis code from the lists provided (including ocular condition ranges and Z96.1 where applicable) and a Table 2 code (92002/92004/92012/92014/92015) or appropriate E/M (99201–99205, 99211–99215) consistent with the level of service documented.

See chunks 17-18.

Refraction services are not separately reimbursable when billed on the same claim with a routine or medical eye exam or an evaluation and management (E/M) service. In addition, repair and refitting of eyeglasses and fitting of eyeglasses (unless billed with new frames and/or lenses) are not separately reimbursable under this policy; these items are listed as coverage exclusions and may be denied when billed independently.

This payment policy is informational only and is not a guarantee of reimbursement. Claim payments remain subject to member benefit coverage, eligibility, claims payment edit rules, documentation guidelines, authorization policies, provider contract agreements, and applicable state and federal regulations. References to CPT or other coding sources are for definitional purposes only; actual payment may vary by claims processing systems and contractual terms.

Replacement of lost or stolen eyewear is specifically listed as non‑covered for Medicaid adults, Commercial, and INTEGRITY members. Providers should not expect reimbursement for claims submitted solely for replacement of items lost or stolen for these member groups.

Coding and Procedure Codes

Routine exam HCPCS CodesHCPCSCovered

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

Medical eye exam and E/M CodesCPTCovered

92002	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
92004	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient; 1 or more visits
92012	Ophthalmological services: medical examination and evaluation; intermediate, established patient
92014	Ophthalmological services: medical examination and evaluation; comprehensive, established patient; 1 or more visits
92015	Determination of refractive state
99201	Office or other outpatient visit for the evaluation and management of a new patient; problem focused history/exam; straightforward medical decision making
99202	Office or other outpatient visit for the evaluation and management of a new patient; expanded problem focused history/exam; straightforward medical decision making
99203	Office or other outpatient visit for the evaluation and management of a new patient; detailed history/exam; low complexity medical decision making
99204	Office or other outpatient visit for the evaluation and management of a new patient; comprehensive history/exam; moderate complexity medical decision making

Diabetic eye exam diagnosis codesICD-10Covered

E08.40-E09.29	Diabetes mellitus with eye complications (range provided)
E09.40-E10.29	Diabetes mellitus codes with eye involvement (range provided)
E10.40-E11.29	Diabetes mellitus codes with eye involvement (range provided)
E11.40-E13.29	Diabetes mellitus codes with eye involvement (range provided)
E13.40-E13.9	Diabetes mellitus codes with eye involvement (range provided)

Examples of medically necessary diagnosis codesICD-10Covered

C69.00-C69.92	Malignant neoplasm of eye (range)
H00.011-H59.89	Disorders of eyelid and orbit through other disorders of eye and adnexa (range)
Z96.1	Presence of intraocular lens

E/M and Ophthalmology Exam Codes (Table 2)CPT

92004	Ophthalmological services: medical examination and evaluation; 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 history/exam; straightforward MDM
99202	Office/outpatient visit new patient; expanded problem focused history/exam; straightforward MDM
99203	Office/outpatient visit new patient; detailed history/exam; low complexity MDM
99204	Office/outpatient visit new patient; comprehensive history/exam; moderate complexity MDM
99205	Office/outpatient visit new patient; comprehensive history/exam; high complexity MDM
99211	Office/outpatient visit established patient; minimal problem

1–10 of 14

1/2

All Other Vision Services (Table 3)mixed

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, unilateral or bilateral
92060	Sensorimotor exam with multiple measurements of ocular deviation
92065	Orthoptic and/or pleoptic training

1–10 of 70

1/7

Typical face-to-face time for E/M codes

99211Typical face-to-face: ~5 minutes

99201-99203Typical face-to-face: 10–30 minutes depending on code (99201 ~10 min; 99202 ~20 min; 99203 ~30 min)

99204Typical face-to-face: ~45 minutes

99205-99215Typical face-to-face ranges: 25–40 minutes depending on code (e.g., 99215 typically ~40 minutes)

Provider Responsibilities and Billing Instructions

Prior Authorization

Verify eligibility and prior authorization

It is the provider’s responsibility to verify member eligibility, benefits, and any prior authorization requirements before rendering services. Prior authorization may be required for certain vision services and hardware; check Neighborhood’s Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 for assistance.

Verify eligibility and benefits before scheduling or providing services.
Obtain prior authorization when required by the plan and document authorization details in the medical record.

Billing Rule

Claim submission and coding standards

Providers must submit complete, accurate claims using the appropriate CPT and HCPCS codes and adhere to contractual timely filing requirements. Coding must follow AMA CPT and HCPCS Level II standards. Incomplete or incorrect coding, missing documentation, or billing for excluded services may result in denial or recoupment.

Background

Vision care includes both screening-level routine examinations and comprehensive medical ophthalmological evaluations. A routine eye exam consists of tests to evaluate visual acuity and screen for eye disease, while a medical (non‑routine) vision exam involves evaluation of a new or existing condition with initiation or continuation of a diagnostic and treatment plan, which may include prescribing medication, ordering further tests, or arranging specialty care. Medical exams trigger different coding and billing expectations than routine exams and should be documented to support medical necessity when applicable.

Definitions

Routine Eye Exam

DefinitionRoutine vision examination involves a series of tests to evaluate vision and check for eye diseases.

Billing codesMust be billed with an appropriate diagnosis (e.g., Z01.01) and a code from Table 1 (S0620 or S0621).

FrequencyRoutine Eye Exam frequency varies by line of business (examples: Medicaid once every 2 years rolling; adults/children per plan year as applicable).

Medical Vision Exam (Non-Routine)

DefinitionMedical vision exams evaluate a new or existing condition and include initiation of a diagnostic and treatment program (may include prescribing medication and arranging specialized services).

Relevant CPT codesUse Table 2 codes (e.g., 92002, 92004, 92012, 92014, 92015) or appropriate E/M codes when initiating or continuing diagnostic/treatment programs.

OpenPayer

Vision care services — coverage and reimbursement (routine and medical eye exams, surgeries, and vision hardware)

Coverage Criteria and Benefits

Coding and Procedure Codes

Provider Responsibilities and Billing Instructions

Background

Definitions