QUEST Integration – Vision Examination With Refraction

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

HMSA transitioned our current vision portfolio to a new vision benefit with EyeMed effective for service dates on or after January 1, 2022, for the following line of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees. HMSA will continue to be the administrators for non-routine vision services through the members medical plan(s). For more information, please contact EyeMed at www.eyemedinfocus.com.

Contact by Phone:

For Providers: 1-888-259-4344

For Service Dates Prior to January 1, 2022

Ophthalmologic Examination

An ophthalmologic exam with refraction includes:

• Determination of visual acuity
• Tonometry (routine and serial)
• Gross visual fields
• Muscle balance
• Slit lamp microscopy

Limited to once in a 12-month period for patients age 20 and younger, and once in a 24-month period for patients age 21 and older. Visits done more frequently are payable when indicated by symptoms or medical condition. Clearly indicate the medical condition with the appropriate ICD-10 diagnosis code or the complaint.

Ophthalmoscopy is payable as a separate procedure. If done within a pre-op period, it is considered a pre-operative examination.

Excluded Vision Services

• Orthoptic training
• Prescription fee
• Progress exams
• Radial keratotomy
• Visual training

Referrals

Routine vision care to determine a patient’s need for corrective eyewear does not need PCP referral. Referral is required if the main purpose of the visit is to diagnose or treat a medical condition. Claims must provide the appropriate diagnosis code indicating whether the visit was for a routine vision exam (e.g., V720) or for a medical condition.

Medical specialists scheduling appointments for a QUEST Integration patient for a medical condition should ensure that a PCP referral was given.

Vision Patient Certification Statement

Always ask the patient when he/she had a vision exam or eyewear. Even established patients should be asked as there is always the possibility that the patient visited another provider without your knowledge. This will enable you to determine whether you will be able to bill QUEST for the services or whether the patient will be responsible. Have the patient sign the Vision Patient Certification Statement [PDF] and keep this form in the patient’s records.

Providers can also check eligibility for vision services and appliances for all QI members online through HHIN+ (HMSA’s Online Provider Portal). The interface will show if the member is eligible for an eye exam or the lenses benefit without having to contact us. If a provider submits a claim exceeding max benefit, the claim will deny. These denied claims must be submitted with documentation of medical necessity or reason for replacement. They will be reviewed by us for appropriate medical necessity or for replacement reconsideration.

Our verification of benefits does not guarantee payment as our records only provide a history of submitted claims on the date that a provider inquires about vision benefits. They cannot account for services that were rendered but not yet submitted for payment. If we respond that the patient is eligible for vision services, your claim may still be denied for exceeding the maximum benefit if we receive another claim before receiving yours.

Revision History