Medical insurances usually don’t cover contacts unless they are considered medically necessary–and even then, many don’t cover at all. Contact lenses are defined as medically necessary when the patient has an eye disease or prescription that has to be managed with contacts because glasses can’t provide sufficient correction. Examples of diagnoses that may qualify for medically necessary contact lenses are keratoconus, aphakia, post-corneal transplant, corneal dystrophies, ametropia, and anisometropia.
Many commercial medical carriers don’t cover medically necessary contacts. If they do, you have to be careful about reimbursements on a commercial fee schedule. Sometimes insurance reimbursements are not enough to cover the office’s cost on specialty lenses because the newer technology is so expensive. Therefore, it is critical to call the patient’s insurance and verify benefits prior to ordering or dispensing contacts. When checking benefit information, always get a dollar amount, not just coverage as a percentage of their allowance. (For example, 80% can mean 80% of $150 or 80% of $1,200. You have to know!) Ensure the insurance allowance is enough to cover your costs because you cannot charge your patient any overage.
Also, with commercial carriers you can file a claim for each office visit during the fitting process. Routine vision carriers treat 92310 as a global fee; however, per CPT coding guidelines 92310 is not actually a global code. Therefore, each time the patient comes into the office, create a claim with a per-visit fee when filing to commercial carriers. NOTE: If the patient’s diagnosis is keratoconus, some commercial companies require that the initial visit be filed with 92072. Follow up visits can then be billed with 92310 or some doctors use a lower level E&M code.
Please note that the rules for filing with routine payers like VSP or EyeMed are different and very clearly defined. However, if you anticipate filing an insurance claim to a medical carrier, you’ve got to know the patient’s benefit before you start the process. In order to help, we have attached a predetermination form your practice can use when verify benefit information with commercial carriers. Just click on the link below!