Routine vs. Medical Eye Exams FAQs

What determines routine vs. medical?

Your reason for the exam, as well as your results will determine whether your insurance company will classify the exam as routine or medical. A routine eye exam is defined by insurance companies as an office visit for the purpose of checking vision, screening for eye disease, and/or updating eyeglass or contact lens prescriptions. Routine eye exams produce a final diagnosis, like nearsightedness, farsightedness or astigmatism.

  VISION PLANS cover routine vision care and are designed to determine a prescription for eyeglasses, provide discounts on eyeglasses and/or contact lenses, and to screen the internal and external health of an eye in a healthy person without known eye disease.
  MEDICAL INSURANCE provides coverage when medical conditions (i.e., diabetes), eye conditions (infections, dry eyes, and cataracts) or an eye disease, such as Glaucoma is present and requires diagnosis, management, & treatment as well as communication with another physician.

What happens if my exam is considered medical?

A claim will be filed with your medical insurance carrier and any co-pays and deductibles for that insurance will apply. Any non-covered service like the refraction may be coordinated with your VISION PLAN.

What is a refraction?

A refraction is the part of an office visit that determines your eyeglass prescription. It typically involves questions like, “which is clearer – option one or option two” as different lens combinations are shown to you. VISION PLANS cover both the routine eye exam and the refraction. MEDICAL INSURANCE may not cover the cost of the refraction.

What if you are not a provider for my VISION PLAN and/or MEDICAL INSURANCE?

We are contracted with many major medical insurance carriers, we well as many vision plans to file claims on your behalf as a courtesy to you. If we are unable to file a claim directly for you, we will provide you with an itemized receipt so you can submit for reimbursement. In order for us to help maximize your benefits it is important that you provide both your VISION PLAN and MEDICAL INSURANCE at time of scheduling.

What else do I need to know?

Our office does not make these rules; they are defined by the insurance carriers themselves. Your insurance is a contract between you and your insurance company. Not all services are covered benefits in all contracts. We often have patients that have both VISION PLANS and MEDICAL INSURANCE. They are very different in terms of the services they cover and it’s important for you to understand those differences.

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