Turning Problems into Profits

Medically Necessary Contacts through Commercial Health Plans

Predetermination Form for Medically Necessary Contacts through Medical Insurances

The rules for filing medically necessary contact lenses with routine payers like VSP or EyeMed are clearly defined and relatively simple.  However, medical insurances don’t always understand the world of optometry, and getting a medically necessary claim to process correctly can be tough.  Many medical insurances don’t cover medical contacts at all, or if they do, they pay so poorly that the office can lose money if they don’t handle these claims correctly.

When you file medically necessary contacts with medical payers, you have to be aware that sometimes they incorrectly hit a routine fee schedule that can significantly lower your reimbursements. When this happens, insurance reimbursements are usually not enough to cover the office’s costs, especially on specialty lenses where 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.

If you anticipate filing an insurance claim to a medical carrier like Blue Cross, Cigna, or UHC, you’ve got to know the patient’s benefit before you start the process.  In order to help, we’ve created a predetermination form your practice can use when verify benefit information with commercial carriers. Either send this form in or use it as a guide on what questions to ask when you call.

Print PDF here:  Medically Necessary Contacts Predetermination for Commercial Insurances