Coverage Policies

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Effective Date: 08/21/2003 Title: Refraction Services
Revision Date: 10/01/2015 Document: BI001:00
CPT Code(s): 92002, 92012, 92014, 92015
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1.    When a refraction is conducted by an optometrist or an ophthalmologist to determine the need for and proper prescription of corrective lenses/glasses, it is covered under your vision services coverage. 

2.    When a refraction is done as part of an ophthalmologist examination because of diagnosed eye disease other than the need for corrective lenses, it is covered under the medical benefit.

3.    When refraction is performed under other circumstances it is not covered.

Medical Statement

1.    CPT code 92015 (determination of refractive state) is payable with a diagnosis code of encounter for examination of eyes and vision (Z01.00, Z01.01) or with a diagnosis reflecting a need for a refraction (e.g.: myopia, hyperopia, etc.: H52.00-H52.4, H52.6-H52.7, and H54.7).
under the vision benefits 

a.    This code is not covered if:

·         There is no coverage for vision services;

·         The claim exceeds dollar limitations on coverage for vision services; or

·         The exam exceeds frequency limitations on coverage for vision services.

2.    When 92015 (refraction) is billed as part of an ophthalmological special examination it is covered under the medical benefit

3.    92015 will not be covered for other uses.


Codes Used In This BI:


92015             Refraction

92012             Eye exam established pat

92014             Eye exam & treatment

92002             Eye exam new patient

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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