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Claims & Payment Policy: New Ophthalmology Medical Necessity Payment Policies

October 1, 2021

The Ophthalmology related medical necessity policies below will be implemented with an effective date of November 1, 2021.

  • Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (CP.VP.14)
  • Extended Ophthalmoscopy (CP.VP.26)
  • Fluorescein Angiography (CP.VP.28)
  • Fundus Photography (CP.VP.29)
  • Gonioscopy (CP.VP.31)
  • External Ocular Photography (CP.VP.43)
  • Visual Field Testing (CP.VP.63)

Providers can review the complete policy at www.wellcare.com/providers, select your state, select Claims, then Payment Policy.

Summary of Policies: As a part of business alignment with WellCare and Centene Corporation, the policies above will be implemented as a synergy effort. These policies include a suite of seven medical necessity eye exam claim denial edits.

What does this mean for providers? Other than the specific procedure and diagnoses codes outlined within each policy, the criteria is the same for all seven policies. Procedure codes associated with the above policies will be denied if none of the medically necessary supporting diagnosis codes are present on the claim submission. Only one medically necessary diagnosis needs to be present for payment of the claim. The medically necessary diagnoses codes for each procedure are included in the policies on our website. The Health Plan recommends that providers review these diagnosis and procedure codes prior to claim submission.

If a provider does not agree with a decision, they may appeal the denial. Medical records will be required to substantiate provider billing.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.

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Last Updated On: 10/1/2021