Insurance can often be helpful, but it can also be confusing and frustrating. When sorting out the details of coverage for vision therapy, the route to successful insurance conclusions is pretty simple if you know what questions to ask, and figure out a plan with input from your vision care provider and your insurance agent.

Most patients will find that initial comprehensive exams are covered. Many policies will also cover an additional exam to evaluate a patient’s visual information processing to determine an appropriate treatment program. That doesn’t mean yours will, however, so please make sure to check with your agent regarding your particular policy.

Some insurance companies offer coverage for vision therapy, but just because they offer it does not mean that your policy includes it. A conversation with your insurance agent or workplace HR department can help you determine what will be covered. Toward that end, there are some important questions to ask that will help in the planning stages of therapy:

• Ask if vision therapy is covered, sometimes referred to as orthoptics in the insurance industry. If coverage is a part of your plan, it might also be smart to ask if there is an annual limit, or lifetime limit, for coverage. Note that vision therapy is most often applied to a medical policy as opposed to a vision policy.
• Ask which CPT insurance billing codes are covered under your policy with regard to vision therapy. Most therapy providers use code numbers 99203, 99204, and 92015 to bill for an initial vision exam of between 1 – 2 hours. For assessing a patient’s visual information processing, and a 2-hour appointment, commonly used CPT codes may include 96111, 96116, or 92060. Therapy sessions lasting up to an hour often use the code number 92065. For progress visits, codes 99213, 92060, 96111, and 96116 are commonly cited.
• Ask if therapy visits must be pre-authorized in order to be covered, and make sure you understand and comply with the requirements.
• Ask what the out of network deductible will be if your provider is not a recognized provider with your insurance company.
• Ask what your coinsurance payment will be once your deductible is met.
• Ask how long it will take for the insurance company to reimburse you.

If you are contributing to a flexible spending health care account, you may be able to apply funds from that account toward vision therapy. Also, should any claims be denied, you have the right to file an appeal, which can resolve in favor of the patient.

The staff at Drs. Tod Davis and Amy Carlyle Developmental Optometry and Vision Therapy Services is there to help patients navigate not only the highly specialized treatment programs and options, but also the sometimes challenging world of insurance codes and processing. Rest assured that Drs. Tod Davis and Amy Carlyle, supported by a superior professional staff, is invested in the wellbeing of their patients, and will go the extra mile to ensure patients receive the treatments they need. Visit www.davisvisiontherapy.com today for more information.


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