Vision test denied coverage

[JohnW14426]

For two years running, I've had trouble with the coverage for my eye exam.  My ophthalmologist (in network) does a comprehensive exam, as I have MD, including refraction (vision test for glasses).  My Humana advantage plan. Mandatory Supplemental Vision Benefit VIS752, says (P88) says I get covered for

Routine Eye Exam (includes refraction) (1 per calendar year)
OR
• Refraction exam (1 per calendar year) when completed at the same appointment as a Medicare covered comprehensive eye exam

The ophthalmologist bill lists 3 services: 92014, 92015,92134. The other exams get covered but the refraction (92015) is rejected by Humana with the following message:

Message:

THIS ROUTINE VISION PROCEDURE IS NOT ALLOWED SEPARATELY. YOU ARE NOT RESPONSIBLE FOR THIS AMOUNT.

I got billed for the refraction but, when I call the eye dr, they say it was rejected by Humana and I should call Humana.  Humana subcontracts to EyeMed and told me to call them.  EyeMed says they never processed the claim because it was medical (processed by Humana) and they don't pay for refraction that's part of a medical exam. They said I should call the eye dr.  I started the circle of calls again, with much the same result and many transfers.  The EyeMed people were adamant that I was responsible and even said that I signed something saying that I would pay for this.  They said they'd start paying for vision tests once I no longer have a medical issue, which will never happen because MD is permanent.  I finally was connected to someone at Humana who said that I was not responsible and they would have someone call the eye dr to sort it out.  I called the eye dr one last time to say that Humana was calling them to sort the bill, which I wasn't paying.  EyeMed said that it's very common that people don't realize their refraction (vision test) isn't covered, so I'm wondering how many people are paying for vision tests when they shouldn't be.  Who is the problem here?  My ophthalmologist, Humana, or EyeMed?  It shouldn't be this confusing.

[GailL1]

@JohnW14426 

Just guessing but it maybe the way that the claim is handled - and how it is being processed or required to be processed by your Humana (added) Vision coverage.

Medicare will ALWAYS deny 90215 because it is not covered under Medicare (and in turn, your Medicare Advantage plan).  

However, since you have this added coverage under the Medicare Advantage plan - Humana advantage plan. Mandatory Supplemental Vision Benefit VIS752 - then it seems that it has to be submitted separately to the insurer.

Since it is never covered under Medicare then there is no need for a denial from Medicare for your (eye) coverage to even be submitted to Medicare and the doc needs to submit it separately.  OR the doc has to submit it with the info asked for by Medicare (see below)

This is not always the case with special benefits of a added supplemental type that a beneficiary might have - many do require that the claim be denied by Medicare before it is processed by the whatever added coverage insurer.  Like my eye coverage - they do require a denial from Medicare for 92015 before they process this part of my coverage but it sounds like this is not the case with you Humana extended eye coversge.

Here’s the Medicare Contractor’s rule of claim coverage from the contractor that services my area - they should all be the same in this regards, I think.

Medicare Claims Processing - Optometry and Ophthalmology: Determination of Refractive State- publish... - (jurisdiction M Part B)

copied and pasted below:

Medicare statutorily excludes payment for determination of refractive state, CPT Code 92015. If the patient asks you to submit a claim for denial or for secondary insurance purposes, submit CPT code 92015 with HCPCS modifier GY. (HCPCS modifier GY indicates that the service is statutorily excluded from Medicare coverage.) If the patient does not need a Medicare denial for refraction then you are not required to submit a claim for an eye refraction. An eye refraction is never covered by Medicare.

This is written to the doc office for claims   submission - not you as the beneficiary.

So my advice here is ask Humana how the claim needs to be submitted for coverage without all the hassles it is causing you - BTW, if you have a Medicare. broker who wrote this Medicare policy for you - ask them because this should be something that they should be able to either answer or can find out for you.

I also found this:  THIS SEEMS TO FIT YOUR SITUATION 

HealthcareManagement Consultant:  04/21/2022. What to do when a Medicare Managed Care Plan changes r...

from this link: (copy & paste)

In January 2022, Humana notified participating providers in a letter that identified refraction services (CPT code 92015 Determination of Refractive State) are considered bundled into the vision codes (92002, 92004, 92012 and 92014) and not payable separately by Humana or the patient. For traditional Medicare, the determination of the refractive state which is necessary for obtaining glasses and includes specification of lens type (monofocal, bifocal, other) lens power, axis, prism, absorptive factor, impact resistance and other factors is considered self-pay (as are most glasses and contact lenses). Under Traditional Medicare the determination of refractive state is statutorily excluded from coverage and is considered self- pay for the patient. The Humana process appears to hold the patient harmless (not financial responsible) for these charges based on the use of the “bundling” process.

It goes on to say what the practice should do - 

There are directions  for this to opthalmologist all over the world wide web - here is another - just so you know.

American Acadamy of Opthalmology (SavyCoder) - Back to the Basics—Coding for Refractions Using CPT C...

Yea, I am probably giving you more info than you need but just imagine how intelligent you are gonna sound to Humana or the Humana broker when you are asking the question about claims submission for this refraction service.

No need for an attorney - just a good broker that knows the product they are selling and keeps up with the changes.

[cat0w]

Have you talked with an attorney?