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09152020 Comprehensive Eye Exam Claim & Payment Policy (effective 10152020)

Claims & Payment Policy: Frequency of Comprehensive Ophthalmological Exams


Dear Provider,

WellCare is implementing the following policy for Frequency of Comprehensive Ophthalmological Exams with an effective date of 10/15/2020.

Summary of Policy:

Per CPT® guidelines, comprehensive ophthalmological services “describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes biomicroscopy, examination with cycloplegia or mydriasis, and tonometry. It always includes initiation of diagnostic and treatment programs”.

In accordance with clinical practice guidelines outlined by the American Academy of Ophthalmology (AAO) and American Osteopathic Association (AOA), WellCare will only reimburse for an intermediate, established patient ophthalmologic services when billed within six months of a previous comprehensive ophthalmologic service for review of the same condition. Should two comprehensive exams be required, it should be documented as such within the medical record and provided with the appeal.

What does this mean for providers?

Comprehensive ophthalmological exams should not be used for checkups when there’s a chronic problem being followed up every few weeks or months. If  a patient is seen for a follow up visit within 6 months of the comprehensive ophthalmologic service (CPT 92014) performed for the same condition, the claim will be down coded to the Intermediate Ophthalmological (CPT 92012) service.   Providers may see the following Explanation Codes on the Explanation of Payment (EOP) if this type of down coding is performed:

  • IH062- E & M Code Level Denied based on info supplied on claim
  • LT062- CPT recoded based on claim info. Medical Records needed.

Wellcare will not reimburse comprehensive exams more than once in a six month period for review of the same medical condition. Medical eye exams may be considered medical necessary only when a disease condition of the eye is found or reasonably suspected. The medical record must clearly document the specific condition or the high risk medication.

If the provider does not agree with a payment determination, the provider has the right to file a grievance by submitting the portion of the medical record that supports additional reimbursement. WellCare will review the submitted medical record(s) to assess the intensity of service and complexity of medical decision-making for the Ophthalmological services provided.

Review the complete policy at, select your state, select Claims, then Payment Policy.

We are here to help. If you need further information, please contact your Network Representative.



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Last Updated On: 12/29/2020