Download Vision - Pediatric and Adult

PROVIDER BILLING GUIDELINES
Vision - Pediatric and Adult
Pediatrics (under 19 years)
In accordance with the Affordable Care Act (ACA) the Payer covers timely pediatric vision
services for the early detection and treatment of eye and vision problems. These covered
services are to be performed in the pediatrician’s office.
Payer covers the following childhood vision screenings in accordance with ACA, The American
Academy of Pediatrics, The American Academy of Ophthalmology, and the American Association
for Pediatric Ophthalmology:
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Newborns to age 3: Red reflex test, corneal light reflection, ocular motility, pupil
examination, external examination, and vision assessment at all well-child visits
Ages 3 to 5 years: Vision screening, with an emphasis on age-appropriate visual acuity testing, each year
After 5 years of age: Vision screening every 1-2 years.
An annual fully dilated comprehensive eye exam with refraction if required.
Correction of refractive error with eyeglasses and contact lenses.
Pediatric Vision Services
EOC Benefits
Covered services for children under age 19 include routine vision services, including services
and supplies to detect or correct refractive errors of the eyes. Covered services are limited to the following:
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Covered services are limited to the following:
Vision exams are covered once every benefit period
Eyeglass frames are covered once every benefit period
Contacts are covered in lieu of eyeglasses if medically necessary. Prior authorization is required.
EOC Exclusions
• Medical and/or surgical treatment of the eye, eyes, or supporting structure, including surgeries to detect or correct refractive errors of the eyes;
• Eye exercises and/or therapy;
• Orthoptic or vision training, submormal vision aids, and any associated supplemental testing;
• Charges for lenses and frames ordered while insured but not delivered within 60 days after coverage is terminated, or vision testing examinations that occur after the
date of termination;
• Charges for lenses that do not meet the Z80.1 or Z80.2 standards of the Americal
National Standards Institute;
• Charges in excess of the allowed amount as established by CHA;
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Vision - Pediatric and Adult
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Oversized lenses;
Corrected eyewear required by an employer as a condition of employment and safety
eyewear;
Non-prescription lenses and frames, and non-prescription sunglesses;
Charges for services or materials from an ophthalmologist, optometrist or optician
acting outside the scope of his or her license; and
Charges for any additional service required outside basic vision analyses for contact
lenses, except fitting fees.
Pediatric Frame Guidelines
The following 2 codes are to be used in billing for the eyeglass frames:
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V2020 – Frames (Standard)
V2025 – Deluxe Frames
The payer only covers the costs of the standard frames.
A Member may choose to select a standard set of frames and only be responsible for any
applicable deductibles and coinsurance. For example, assuming the regular billing for standard
frames is $150, the provider should bill the following:
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V2020 – $150
The V2020 code will process with the allowed amount equal to the contracted amount with
the Member’s deductibles and coinsurance being applied. The difference between the billed charges ($150) and the contracted allowed amount is considered network discount with no
Member liability.
If a Member chooses to upgrade to a deluxe frame, the provider may charge the Member the
difference between the standard frame and the deluxe frame charges. The provider must explain
the pricing difference to the Member and is required to obtain signed documentation from the
Member that they understand the pricing difference and the additional financial obligation.
If a Member chooses a deluxe frame, the provider is to submit claims with two separate line
items. The first line with V2020 is the regular billing for the standard frames. The second line is
to use V2025 for the additional charges (differential) for the deluxe frames.
For example: A Member chooses deluxe frames with charges of $350. The provider obtains
signed documentation from the member that they understand the additional Member liability.
Assuming the regular billing for standard frames is $150, the provider should bill the following:
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V2020 – $150
V2025 – $200 (charges differential)
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Vision - Pediatric and Adult
The V2020 code will process with the allowed amount equal to the contracted amount with
the member’s deductibles and coinsurance being applied. The difference between the billed charges ($150) and the contracted allowed amount is considered network discount with no
Member liability.
The V2025 code will process as non-covered with Member liability of $200. The provider is able
to collect this amount from the Member.
Adults (19 years and over)
Payer does not cover routine vision exams including refractive services, eyeglasses or contacts
in adults. We will cover most services required to identify or treat a medical condition such as
infection, corneal disorders, cataracts, glaucoma, double vision, dry eye, macular degeneration,
and diseases of the eye caused by diabetes.
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