[Provider] Billing Refractions and Comprehensive Eye Exams

[Provider Notification]

ATTENTION: All Section 75, Vision Providers

 

We recently discovered that some providers have been billing for
Refractions (92015) along with Comprehensive Eye Exams (92014 or 92004)
on the same date of service.  The Refraction is included in the
Comprehensive Eye Exam for MaineCare and should not be billed separately
from the Comprehensive Eye Exam (92014 or 92004).  Included below is
Section 75.03-1 of the MaineCare Benefits Manual, Section 75, Vision
policy.

 

The exception is when billing after Medicare.  Medicare does not
reimburse for the Refraction, therefore, the Refraction is separately
billable to MaineCare when billing after Medicare.

 

MaineCare has overpaid for Refractions provided on the same date of
service as Comprehensive Eye Exams (92014 or 92004).  Please void the
MaineCare claim if you have been overpaid.  

 

In some cases, MaineCare paid the Refraction first, and denied the
Comprehensive Eye Exam.  In these cases, please submit a void for the
Refraction.  Once the void is listed on a Remittance Advice Statement,
you can then bill for the Comprehensive Eye Exam.

 

We apologize for any inconvenience this may have caused.  Please contact
Provider Relations at 1-800-321-5557, option 8 with any questions.

 

 

75.03-1

3.   Eye Examination - Comprehensive

 

A comprehensive eye examination is a level of service involving an
in-depth evaluation of a member with a new or existing problem requiring
the development or complete re-evaluation of data.

 

Example: The examination of the eye and related structures to ascertain
defects or abnormalities, to detect the presence of eye diseases, to
determine the refractive and accommodative states of the eyes, and to
evaluate the visual functions. The eye examination includes a diagnostic
history, visual acuity determination, testing for refraction, muscle
balance and accommodative function, ophthalmoscopy and biomicroscopy.
Tonometry and gross visual field testing should be included when
indicated. Other tests may be included as required as long as they fall
within the scope of licensure for optometry.

 

 

This is a one-way communication.  Please do not respond to this message.

 

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