Eye exams can be covered under either MEDICAL Insurance or VISION Plans, depending on the presenting symptoms or findings of the eye exam. This form helps provide clarity on the different services our office offers in order to provide you with the appropriate care for your eye/vision concerns. Please note that these filing requirements are defined by your Vision Plan and Medical
Insurance.
VISION Plan:
- Covers 1 routine “wellness” exam per year, including an overall eye health screening and refraction (update a glasses prescription)
- Does not cover the evaluation/testing for medical problems such as: redness, dryness, itching, cataracts, diabetic eye exams, nor the release/refill of a medication prescription.
- Does not cover retina photos or specialized disease testing
VISION plans typically cannot be filed on the same day as MEDICAL insurance. Therefore, a second appointment (under your MEDICAL insurance) may be necessary to further evaluate medical eye concerns such as redness, itching, cataracts, diabetes, etc.
MEDICAL Insurance:
- Covers unlimited office visits with symptoms like burning, itching, redness, allergies, headaches, blurred vision, watering, light sensitivity, pink eye, etc.
- Covers visits for more serious eye conditions like cataracts, glaucoma, diabetes, macular degeneration, and eye surgery
- Covers high-tech diagnostic instrument testing (e.g., retina photos, visual field, glaucoma testing)
- Does not cover checking for glasses prescriptions/”refractive” conditions (near-sightedness/myopia, astigmatism, etc)
- Your co-pay/co-insurance/deductible may apply to each visit (defined by your MEDICAL insurance)
MEDICAL insurance must be filed based upon details of the eye exam, the symptoms which were presented during the eye exam, the diagnoses made during the eye exam, high-tech diagnostic instrument testing, and/or if a prescription for medication is needed.
DIABETES:
Chronic conditions such as DIABETES, dry eye, glaucoma or macular degeneration are NOT “routine” since they can have long-term vision consequences and require more complex evaluation and coding of the eye exam. These visits will be filed to your MEDICAL insurance. A summary of today’s eye exam results will be faxed to your Primary Care Physician.
MEDICARE Patients:
Medicare allows for unlimited visits for the diagnosis/treatment of medical eye problems or chronic medical conditions which can affect the eye (dry eye, eye allergies, diabetes, etc.). Medicare does not pay for routine/”wellness” vision exams. Co-pay/deductible may apply.
REFRACTIONS:
A refraction is the part of an office visit that determines your eyeglass prescription. It typically involves questions like, “which is clearer – one or two”. VISION plans cover both the wellness exam and the refraction. MEDICAL insurance (including Medicare) considers checking for a glasses prescription as “routine” and so typically does not cover the cost of the refraction, which is $50.00 and due at the time of service.
***Co-pays, co-insurance, deductibles, and payment for non-covered services are due at the time of service.
*** Some Medical insurances require a referral from their primary care providers to proceed with a medical exam.
