In today’s health care world, insurance coverage can be confusing especially for eye care. We have put together frequently asked insurance questions by patients to help you better understand insurance coverage.
Tri-County Eye Physicians & Surgeons accepts a variety of insurance plans for both medical eye examination coverage and routine eye health examinations.
A medical exam is performed if you have an eye-related medical problem, such as an eye injury, pink eye, double vision, headaches, cataract, dry eyes, glaucoma, or issues related to diabetes or high blood pressure (among many others). In these cases, your medical insurance will be billed for the medical eye exam. Your medical insurance co-payments and deductibles prevail and must be paid at the time of your examination. If your medical insurance requires co-insurance (meaning that you pay a percentage of the charges even after your co-pays or deductibles are met), you will receive a statement from us after your visit. Remember, if we do file the medical exam with your medical insurance, you can still use your Vision Plan benefits toward the purchase of glasses or contact lenses, based on your plan and allowances. At times it can seem like a complicated process, but these are the rules set by the insurance companies. We would be happy to answer any questions that you may have about your coverage.
As part of a routine eye health exam, our doctors examine your eyes for routine eye health and to determine the need for glasses (refraction) or other refractive correction. It is important that you understand that your Vision Plan (VSP, Superior, Davis Vision, EyeMed, etc.) covers ROUTINE well-care exams only, which includes the refraction to determine your eyeglass prescription. Your plan may also provide discounts or allowances toward eyeglass frames, lenses, or contact lenses.
If a medical eye condition is known, or discovered during this eye health exam, a separate exam must then be made to address these issues and will be filed under your medical insurance. If your routine eye health examination reveals a medical condition or disease which requires special testing or follow-up care, the testing and subsequent examinations will be billed to your medical insurance as these are NOT COVERED by your Vision Plan.
It is important to know that if you have a specific eye or vision complaint which is related to a new or pre-existing condition, such as cataract, glaucoma, diabetes, dry eyes, etc., or if you are here for a follow up appointment for a pre-existing condition as requested by a doctor, then your visit is NOT COVERED by your Vision Plan and will be billed to your medical insurance. Unfortunately, the doctor cannot always be sure whether a complaint such as decreased vision is related to a medical eye condition until after you are thoroughly examined.
Once your exam has been filed with your insurance provider (at the conclusion of your visit) we CANNOT ALTER or CHANGE your examination documents or diagnosis codes or bill the other insurance.
When you have medical coverage through an HMO, a referral is required to see our physicians for medical visits. For these patients, lack of the appropriate referral at the time of the appointment will necessitate payment in full at the time of the visit. If this is not possible, a re-scheduled appointment within a reasonable time frame will be made to accommodate your referral acquisition from your primary care physician.
It is important that you understand that your Vision Plan (VSP, Superior, Davis Vision, EyeMed, etc.) may also provide discounts or allowances toward eyeglass frames, lenses, or contact lenses. Our optical and optometry staff will assist you in determining your benefit.
As always, we are available to answer questions that you may have regarding your insurance coverage. You may direct your inquiries to our Insurance and Billing Department by calling 215-396-4211 between 8:00 a.m. and 4:30 p.m. Monday through Friday.