Third-Party Information
How to Bill Humana Insite and Humana Vision Plans Administered Through EyeMed for Medically Necessary Contact Lenses
*Excludes Humana Medicare Plans
On October 15th, 2019, COA's Third Party Committee Charis, Dr. Kevin Krajewski and Dr. Jason Ortman, met with personnel from Humana to request clarification on their billing process for medically necessary contact lenses. Here is what you need to know:
- These are handled differently than traditional bundled medically necessary services and materials associated with other EyeMed plans.
- Prior authorization is required for Humana Vision plans administered through EyeMed excluding Humana Medicare. The form can be obtained through the inFocus EyeMed website. It must be faxed in along with complete clinical medical records from the comprehensive exam , including any diagnostic tests and a material wholesale invoice or wholesale estimate from the contact lens manufacturer. Upon successful submission and review, the provider will receive an approval for an amount for the initial fitting fee visit and an amount for the initial set of lenses.
- Any additional visits or any diagnostic testing should be billed to the patient or the patient's medical insurance plan.
- It is critical that the keratometry readings, refraction with best corrected visual acuity, any pertinent slit lamp findings and topographic findings are submitted with the initial request.
- Previous refractive surgery will disqualify a patient from the Medically Necessary Contact Lens benefit. The elective contact lens benefit can be used in those cases.
- Any additional contact lenses beyond the first set are to be billed to the patient. In cases of disposable or frequent replacement contacts, the patient is responsible for any lenses beyond the first box.
- Humana has stressed that incomplete records are the main reason for downgraded reimbursement.
Authorization forms with patient information should be sent to the fax number 866-685-2759. If a response takes longer than 10 days, please reach out to jcruze@humana.com for expedited review.
Take home messages:
1. These plans are unbundled services and materials, so it is important to bill accordingly.
2. The medical record will determine your reimbursement, so submit a compete record.
Detailed process information: https://www.eyemedinfocus.com/provider-manual/plan-benefits/special-claims-processes/, https://www.eyemedinfocus.com/provider-manual/plan-benefits/humana-vision-medically-necessary-contact-lens-benefits/
Authorization form: http://apps.humana.com/marketing/documents.asp?file=3080064
