Insurance and Billing · Medical Insurance
Commercial Medical Plans BCBS, UnitedHealthcare, Aetna, Cigna and Humana.
Medical eye care for working-age patients is billed to their commercial health plan, while routine vision care often runs through a separate vision product. Many of the big medical carriers hand that vision product to a vision network, so one patient can bring you two payers.
Quick answer
Know which product each card represents.
A commercial medical plan pays for medical eye problems: a diagnosis, a test or a treatment plan. Routine exams and eyewear depend on whether the member has a vision benefit, and that benefit is frequently run by a vision company. Aetna Vision and Cigna Vision, for example, use networks serviced by EyeMed, and UnitedHealthcare vision plans are administered with Spectera. Payer policies also spell out which exam codes go with which kind of visit.
Key takeaways
- Medical eye visits go to the medical plan; routine care goes to the vision benefit.
- Aetna Vision, Cigna Vision and some Humana Vision plans run on EyeMed networks.
- UnitedHealthcare vision plans are administered by Spectera with UHC affiliates.
- Blue Cross Blue Shield of Rhode Island directs routine exams to S0620 and S0621, and medical exams to 92002 to 92014.
- Payer policies differ by state and product, so read each plan's payment policy.
Who runs the vision side for each carrier.
Where the large medical carriers publish their vision network arrangement.
| Medical carrier | Vision product | Network or administrator |
|---|---|---|
| Aetna | Aetna Vision and Aetna Vision Preferred | Network administration through EyeMed Vision Care, LLC |
| Cigna | Cigna Vision | Cigna Vision Network, serviced by EyeMed |
| UnitedHealthcare | UnitedHealthcare vision plans | Administrative services by Spectera, Inc. and UHC affiliates |
| Humana | Humana Vision | Network access based on the EyeMed Insight network (North Carolina plan summary) |
| Blue Cross Blue Shield | Varies by independent Blue plan | Some members carry a standalone vision plan; follow that plan's rules for routine care |
Arrangements vary by state and product year. Check the vision ID card and the plan's provider manual.
A worked payer example: Blue Cross Blue Shield of Rhode Island.
One published payment policy shows how a commercial payer separates routine and medical eye exams.
| Situation | What the policy says |
|---|---|
| Member has a standalone vision plan | Providers who also participate in that vision plan should file routine eye care to the vision plan |
| Visit scheduled as routine, no medical complaint (commercial) | Bill S0620 (new) or S0621 (established), even if a condition is found during the exam |
| Medical exam with a diagnostic or treatment program | Bill 92002 or 92004 (new) and 92012 or 92014 (established) |
| Refraction | 92015 is not separately reimbursed with a routine or medical exam |
| Annual dilated diabetic exam | Treated as a medical exam and coded by level of service; tell the patient it is not a routine visit |
| Screening or refractive care coded as 92002 to 92014 | Called misrepresentation in the policy |
BCBSRI payment policy, last reviewed March 2024. Each Blue plan publishes its own rules.
Getting paid by commercial medical plans.
Steps that apply across carriers.
| Step | What to do |
|---|---|
| Credential | Keep a complete, current CAQH profile; many plans use it for applications |
| Verify | Check medical and vision eligibility separately before the visit |
| Schedule | Record the reason for the visit; it drives which exam code applies |
| Document | Support the diagnosis and the plan of care for every medical exam |
| Collect | Tell patients up front what the plan will not pay, such as refraction or take-home products |
Put the reason for the visit in the schedule, not just the chart. Payer policies like the BCBSRI example decide the code by why the patient booked, so a front desk that captures the complaint saves the biller from guessing.
RescueLink
Send the cash-pay products home with the patient.
Vision and medical plans rarely pay for the drops, lid care and supplements a patient uses at home. Send the exact items by text or email; the patient orders in one tap, refills can run on auto-ship, and your practice earns a 15% participation credit on eligible OTC orders on VisionRescue.com. Contact lenses and Rx products are excluded.
- No setup fee, subscription or minimum
- One-tap ordering for the patient
- Optional auto-ship on refills
- Your recommendation stays with your practice
Questions practices ask
Do commercial medical plans cover routine eye exams?
Sometimes, as a limited benefit. Many members get routine vision care through a separate vision product instead.
Why does an Aetna patient's vision claim go to EyeMed?
Aetna's vision products use network administration through EyeMed Vision Care, which also contracts and credentials the providers.
What are S0620 and S0621?
HCPCS codes for a routine ophthalmological examination including refraction, for new and established patients.
When are 92002 to 92014 used?
For medical examination and evaluation with initiation or continuation of a diagnostic and treatment program, not for screening or refractive care.
Is refraction paid separately?
Under the BCBSRI policy, 92015 is not separately reimbursed. Other payers vary, so check each policy and tell patients when they will owe.
How should a diabetic eye exam be billed?
BCBSRI treats it as a medical exam coded by level of service. Medicare also covers it yearly under Part B.
References
- Blue Cross & Blue Shield of Rhode Island. Payment Policy: Ophthalmology Examinations and Routine Eye Examinations. BCBSRI (PDF)
- Aetna. Aetna Vision Preferred network options. Aetna (PDF)
- Cigna. West Virginia network access plan, Cigna Vision (serviced by EyeMed). Cigna (PDF)
- UnitedHealthcare. Vision insurance plans for employers. UnitedHealthcare
- Humana. Humana Vision plan summary, North Carolina. Humana (PDF)
About this guide
Written for licensed eye care practices by the Vision Rescue team from plan, CMS and payer sources listed above. Questions: providers@visionrescue.com or 1-855-692-8024.
Important notes and disclosures
General business information only, not legal, billing or coding advice. Plan names, programs, policies and codes change; confirm details in each plan’s current provider manual and the member’s benefits before you bill. Vision Rescue is not affiliated with or endorsed by any plan named here. CPT is a registered trademark of the American Medical Association. Vision Rescue is a distributor of medical supplies and over-the-counter products.
Bill the right plan the first time.
Stock the essentials at wholesale and route take-home care through RescueLink.