INSURANCE COVERAGE DETAILS

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Optometry Insurance Coverage Details

Optometry insurance coverage can be complicated and often overwhelming. At Real Eyes Optometry, we want to help you understand how to use your insurance.

MSP covers one full examination per year for children up to 18 years of age and partially covers individuals over 65 years of age.

Optometry insurance coverage does not provide reimbursement for individuals aged 19 to 64 unless they have a medical issue that falls within the MSP guidelines. Guidelines are discussed below.

 

The following is a list of Optometry insurance coverage providers our office can directly bill:

For more info on MSP in British Columbia please check out this link.

Pacific Blue Cross
Green Shield Canada
SSQ Financial Group
Sun Life Financial
Great West Life
Manulife Financial – Standard Life
Desjardins Insurance
Chamber of Commerce Group Insurance
CINUP

Cowan Insurance
First Canadian Insurance
Group HEALTH
Group Source
Industrial Alliance
Johnson Inc.
Johnston Group Inc.
Manion
Maximum Benefit

Real Eyes Optometry can directly bill your insurance provider. All you need to bring to your appointment is your Picture ID and Insurance Card.

Optometry Insurance Coverage, What to Expect During Your Eye Exam

Optometry Insurance Coverage on Eye Examination Benefits

Copy from the BC MSP Guidelines: Routine eye examinations are not an MSP benefit for individuals aged 19 to 64 years. Medically required eye examinations continue to be a benefit for all MSP beneficiaries. We are providing the following information to clarify the changes to the eye examination benefits and to provide more detail on when a referral is required.

According to Optometry Insurance Coverage with MSP, an eye examination is an insured benefit if medically required. The diagnoses which meet the MSP definition of medically required are listed by ICD9 code, and are payable at the frequency indicated on the website. To support exceptions to these frequencies or for other special circumstances, please ensure this information is included with your referral.

In general, the criteria for medically required Optometry Insurance Coverage includes:

  • ocular disease, trauma or injury
  • systemic diseases associated with significant ocular risk (e.g. diabetes)
  • medications associated with significant ocular risk

Formal referrals to ophthalmologists or direct requests to optometrists for an eye examination on behalf of patients are appropriate only if, in the practitioner’s judgment and based on clinical evidence, there is a medical necessity for the examination.

Refractive change (needing glasses or contact lenses) with no other pathology does not meet the MSP medically required criteria for payment. Patients presenting with refractive change only should not be formally referred for an eye exam by you or your office. These patients should contact their ophthalmologist or optometrist directly to request an eye exam and they should also be advised that payment of the eye examination would be their responsibility.

MSP will be monitoring billings and conducting audits of referrals to assess compliance with the criteria defining medically required services.

Optometry Insurance Coverage: Medically Required Eye Examinations

An eye examination is an insured benefit if medically required. The diagnoses which meet the MSP definition of medically required are listed below by ICD9 code, and are payable at the frequency indicated. To support exceptions to these frequencies or for other special circumstances please ensure this information is included with your referral.

In general, medically required examinations include the following:

  • ocular disease, trauma or injury
  • systemic diseases associated with significant ocular risk (e.g. diabetes)
  • medications associated with significant ocular risk

It is appropriate to bill 02015 in the following situations:

For eye exams that meet the medically required criteria, but are not initiated by a GP referral.

Optometry Insurance Coverage