We participate with most insurance and managed care plans including Anthem/Blue Cross Blue Shield, Medicare, ConnectiCare, Aetna, United Healthcare, Cigna,
Vision Service Plan, Oxford, EyeMed, Private Health Care Systems, Tricare, Harvard Pilgrim, HealthyCT, and others.
Many managed care plans limit the types
of services or products they cover. We offer a complete range of services and products and work with your primary care physician and managed care plan to
offer you the highest quality products and services available. You are always in control of your health care and can rely on us to offer all options available
to you regardless of your coverage.
Knowing Your Insurance Coverage: Routine vs. Medical Eye Exams
Dr. Sturgis and Dr. Motto provide all of their patients with comprehensive eye examinations that not only include a refraction
to determine your eyeglass prescriptions, but also a series of diagnostic tests to evaluate the health of your eyes and order
additional tests or prescribe appropriate treatment should medical eye conditions exist.
Many patients with separate vision insurance assume that their vision plan covers any and all eye care. Conversely, patients
with medical plans often assume that they do not have coverage for eye care because they did not purchase a vision plan. This
is not always the case. It is important to know the allowances and limitations of your vision and medical insurance plans for
routine eye examinations, medical eye care, and hardware such as glasses and contact lenses. Some plans have frequency
limitations such as calendar year, every 12 months, or every 24 months for exams and hardware. Other plans may not cover the
Prior to the exam, it is often difficult to determine whether or not your exam will be considered
"routine". Many times vision
problems and medical problems overlap with the same set of symptoms. In order to qualify for a routine vision designation,
the patient must have no complaints related to medical eye conditions, no current or previous known medical eye conditions, no
systemic diseases that typically cause eye problems such as diabetes, and take no medications that commonly cause side
effects in the eyes. The only diagnoses that are considered routine are diagnoses of refractive error
- i.e. you only need
eyeglasses - myopia, hyperopia, astigmatism, and presbyopia. Any other diagnosis is considered medical. Once a medical
condition is diagnosed, all future examinations will be considered medical unless the condition is temporary.
Although you may only be coming in to get a new prescription, you are getting a comprehensive exam and your doctor is
obligated to report any and all diagnoses and conditions when billing your insurance. This may affect service coverage,
including copays and deductibles, so it is important to understand your plan. Insurance companies process claims based on
procedure codes and diagnosis codes. Your doctor cannot manipulate medical coding to
"pick-and-choose" the most convenient
coverage for you without submitting a fraudulent insurance claim. We try our best to let you know your financial responsibility
and of any foreseeable claim denials. However, quoted benefits are never a guarantee of payment and you are ultimately
Some Common Conditions That Require Your Medical Insurance to be Billed
We're Here To Help
- Glaucoma/Glaucoma suspect - Glaucoma is a leading cause of blindness. If there is glaucoma or a risk of developing glaucoma your doctor needs to continually evaluate your eye conditions and may need to perform continued advanced medical testing and prescribe treatment when necessary.
- Macular Degeneration - Age-related macular degeneration is a common eye disease that can cause loss of central vision. Retinal photographs and other diagnostic imaging may need to be performed to monitor the condition.
- Diabetes/Diabetic Retinopathy - Weakening of the blood vessels that nourish the retina can result from diabetes. New vessels may grow but be distorted and bleed, which can injure the retina and cause loss of vision. This condition should be closely monitored and your doctor may need to perform advanced testing to determine if treatment is needed.
- Retinal Degeneration - There are common retinal degenerations that can lead to retinal tears and detachments. These need to be periodically evaluated to determine if surgical intervention is required.
- Cataracts - Cataracts are clouding of the eye's natural lens, which helps to focus light onto the retina. Generally, cataracts are age related but can be due to other medical conditions. If clouding becomes severe and affects vision, surgery can be performed to remove the cataract.
- Nevus - A nevus is a freckle inside of the eye. It is usually asymptomatic and benign but needs to be monitored closely to detect any changes as it could become a malignant melanoma. Your doctor will most likely need to take retinal photographs to monitor the nevus.
- Dry Eye Syndrome - Dry eye occurs when your eyes do not produce enough of their own tears or the tears do not have the right composition to properly lubricate the eye. If left untreated, serious damage to the eye tissue, including corneal scarring and loss of vision, can occur. Continued evaluations are required.
- Blepharitis - Blepharitis is an inflammation of the eyelid margins that can cause complications including styes, conjunctivitis, scarring, injury to the eye tissue (corneal ulcers), and infection.
- Floaters/Flashers - In most cases these symptoms are benign, but should be evaluated because they can be signs of retinal tearing or detachment, which requires immediate medical treatment.
- Risk of eye disease related to systemic diseases
- Risk of eye disease due to long-term use of certain medications
All of the staff at New England Eyecare are very knowledgeable about insurance plans and medical billing and coding. However,
it is impossible to know the specifics of each and every plan, which is why it is important for you to understand your unique
coverage. Of course, we are always happy to answer any questions you have about the eye care you receive from our doctor
and how it relates to your insurance claim.
Frequently Asked Questions
I came in for a routine eye exam, not a medical exam. Why is my medical carrier being billed?
Billing and coding is determined by the patient history, testing conducted, complexity of medical decision making, and diagnoses
found. In general, if you have conditions other than simply the need for glasses, the medical carrier needs to be billed.
The doctor didn't do any additional testing and I don't need any follow-ups. Is it still necessary to bill my medical carrier?
Generally yes, but each patient's situation is different. Again, billing and coding is determined by the patient history, testing
conducted, complexity of medical decision making, the diagnoses found and sometimes specific policies of the insurance companies.
What is the benefit of purchasing a vision plan if it cannot be billed for my exam?
Most vision plans cover glasses and/or contact lenses. For many patients, using the vision plan for materials provides a great deal of
savings and may be beneficial even if the exam is not covered.
Why do I have a deductible?
Many medical plans, including Medicare, have a yearly deductible which must be met before services are paid. Services applied to your
deductible are covered, but must be paid for out-of-pocket until the deductible amount written in your contract is met. Once you meet
your deductible, you may also have a coinsurance. For example, you may be responsible for 20% of the cost of services.
What is a refraction and why is it not covered?
The refraction is the portion of your eye exam that determines your eyeglass prescription. Some insurance companies consider this
"routine" and will deny the claim if there is no routine coverage on the plan, while paying the medical portion of your exam. If this
happens, and you have a separate vision plan, we may be able to bill the refraction to that plan. Otherwise, this may become your