Are any eye exams covered under regular health insurance?

Question

I'm just confused. We have typical BCBS health insurance, and I took my daughter to have an eye exam with our pediatrician. She did a checkup, a vision exam, and then referred us to a pediatric ophthalmologist because it looks like my daughter is having vision problems so they need to check if her eyes are developing normally.

Afterwards, I called up BCBS member services to make sure the referral would be covered, and they said that visit w/ the specialist would be.

But then today I got a claim denial form in the mail saying that the initial pediatrician visit wasn't covered at all because we don't have vision coverage. (We haven't even gone to the specialist yet.)

Why would one be covered and the other not? What could I say if I filed an appeal?

Answer 1

Vision exams and checkups are not usually covered on a health policy. Medical problems with the eyes are, so if the doctor suspects a medical problem and referred you to a specialist it would be covered.

Answer 2

Vision exams are billed two different ways.  One being a routine exam and the other being a medical vision exam.  Whether an insurance company covers it is based solely on the diagnosis that the provider submits.  If the provider submit the claim to your insurance and bills with a diagnosis code that means routine and you have no routine eye coverage than it will be denied. If you took your daughter for fluttering of the eyes than it sounds to me like it should have been submitted as a medical eye exam and should be covered. I would suggest contacting the provider and asking them to resubmit with a medical diagnosis and even a routine diagnosis as the secondary diagnosis.  The insurance looks as the primary diagnosis and your claim could be reconsidered.  If the provider will not resubmit then you can write a letter of appeal to your insurance company letting them know that your daughter was seen due to fluttering of the eye and not for routine purposes. The insurance company may request the medical records from the provider however it may very well get covered.  It is definitely worth trying to get it reprocessed.  

Answer 3

My insurance - Coventry - covers routine eye exams, but this is the first health insurance I've ever had that does that.  I'm suprised your pediatrician did not know that.  I would appeal to the pediatrician, and have her assistance and her office's assistance in resubmitting the claim.  Bring your benefits booklet with you the next time you see the pediatrician, and/or schedule a meeting with the person in their office that's responsible for insurance billing.

Answer 4

Usually routine eye exams are not covered but visits for eye problems are.  Had you taken her to the pediatrician because she was having an eye problem, the visit would have been paid but since it was a routine check-up that uncovered a problem, it's not.

If you can make an argument that you brought her to the doctor because of a problem she was having, you may prevail on appeal.

Good luck - especially to your daughter.

Answer 5

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