Vision Patient Certification Statement - Exam

Effective January 1, 2022, HMSA has partnered with EyeMed for routine vision services for the following lines of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees.
Non-routine vision services remain under our medical benefit and will be processed as such.
For more information, please visit EyeMed at www.eyemedinfocus.com.

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-9 diagnosis code or the complaint.

Ophthalmoscopy is payable as a separate procedure. If done within a preop 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 patient for a medical condition should ensure that a PCP referral was given and registered with HMSA. PCPs are encouraged to register referrals in a timely manner.

Vision Patient Certification Statement

If the patient's last exam or eyewear was more than 24 months ago (12 months for children), have the patient sign the Vision Patient Certification statement and keep this form in the patient's records. If we deny your claim for exceeding the maximum allowed benefit, submit the claim for reconsideration with a copy of the signed and dated form. Having the patient sign the form is not a substitute for checking your records of established patients. We will not honor claims with the form if our records indicate that you previously rendered services within the benefit period.

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 member is eligible for vision services, your claim may still be denied for exceeding the maximum benefit if we receive another claim before yours.

Revision History