Optometry is the only specialty we bill where the same patient, in the same chair, on the same day, may need to be billed to one of two entirely different insurers depending on why they came in. Get that decision wrong and the claim is either denied or paid at a fraction of what it should have been.
Our optometry billing services run both tracks, and our optometrist credentialing service covers both networks.
Vision plan or medical plan?
The rule that decides the claim
The reason for the visit decides the payer, not the findings. A patient coming in for a routine check of their glasses prescription is a vision plan claim even if you discover a cataract. A patient coming in because of flashes, floaters, pain, redness or to monitor diabetic retinopathy is a medical claim even if the exam ends up normal and you also update their prescription.
| Vision plan | Medical plan | |
|---|---|---|
| Typical carriers | VSP, EyeMed, Davis Vision, Superior Vision, Spectera | Medicare, Medicaid, BCBS, Aetna, UHC, Cigna |
| Covers | Routine exam, refraction, materials allowance | Medical eye conditions, diagnostic testing, treatment |
| Codes | 92002 to 92014 with a routine diagnosis; refraction 92015 | 92002 to 92014 or 99202 to 99215 with a medical diagnosis |
| Credentialing | Direct with each vision plan | Standard medical credentialing, CAQH driven |
| Refraction | Usually covered | Usually non-covered; bill the patient with notice |
Two credentialing tracks
- Vision plans credential directly, on their own forms and portals, often with a panel and location application rather than a CAQH pull. Materials and lab arrangements are usually part of the same contract.
- Medical plans credential optometrists like any other provider: CAQH ProView, 120-day re-attestation, primary source verification, committee review. Medicare enrollment goes through PECOS.
Practices routinely complete the vision side and stop, then spend years billing routine-only and referring out medical work they are qualified to do. See our credentialing services for the medical half.
Diagnostic testing and modifiers
- 92083 visual field, 92133/92134 OCT of optic nerve or retina, 92250 fundus photography, 76514 pachymetry.
- 92133 and 92134 cannot both be billed the same day: one OCT code per date of service.
- Testing needs a supporting diagnosis and a documented reason; frequency limits apply per condition on most plans.
- Modifiers 24, 25 and 59 separate an office visit from a procedure or test performed the same day. Missing modifier 25 is the most common bundling denial in optometry.
- RT and LT for laterality, and modifier 50 where a bilateral procedure is billed on one line.
Contact lens and materials billing
Contact lens fitting (92310 to 92317) is separate from the exam and separate from the materials. Medically necessary contact lenses, keratoconus, post-surgical, irregular astigmatism, can qualify under the medical plan where routine fitting would not, at a materially better rate. It is one of the most commonly missed lines in optometry billing, and it needs the diagnosis and documentation to support it.
What we do every week
- Dual eligibility checks: vision benefit and medical benefit, before the visit.
- Payer routing based on the documented reason for the visit.
- Charge entry with correct exam, testing and materials codes.
- Modifier scrubbing: 24, 25, 59, RT/LT and 50.
- Refraction handling: billed to the patient with notice where non-covered.
- Denial management, especially bundling and frequency-limit denials.
- Payment posting across both plan types and aged AR recovery.
Related pages
- Surgical eye careophthalmology billing services ASC privileges, surgical global periods and co-management.
- Credentialingmedical credentialing services the medical-plan half of an optometry practice.
Optometry billing FAQs
How do I decide between the vision plan and the medical plan?
By the patient's stated reason for the visit, documented at check-in. A routine prescription check is vision; a complaint or monitoring of a medical condition is medical. The findings do not change which plan the visit belonged to.
Can I bill both plans for the same visit?
Not for the same service. You can, where the payer allows it, bill the medical plan for the medical exam and the vision plan for the refraction or materials, but not the same exam to both.
Is refraction ever covered by medical insurance?
Rarely. Medicare excludes it, and most commercial medical plans follow. It is normally billed to the patient, which needs to be disclosed before the exam rather than discovered at checkout.
Do we need separate credentialing for VSP and EyeMed?
Yes, each vision plan credentials separately on its own forms, and neither counts towards your medical plan credentialing. They are independent tracks.
Talk to an optometry biller
Send us a month of claims. We will show you how many visits were routed to the vision plan that should have gone to the medical plan.
Schedule a billing demo Talk to a billing expert