Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



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.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.

Coverage Policies

Important! Please note:

92015 Refraction

92012 Eye exam established pat

92014 Eye exam & treatment

92002 Eye exam new patient