Vision Services

Medical Coverage Guidelines

Medicaid Vision Manual 

Please note that coverage guidelines and procedures are subject to change. Refer to the monthly Provider Update for recent changes.

• Vision Coverage Guidelines
  
  • Provider Participation Guidelines
  • Recertification
  • Reimbursement Guidelines
  • Medicare/Medicaid Crossover
  • Patient Liability
  • Covered/Non Covered Services
  • Replacement items
  • EPSDT 
  • Contact Lenses
  • Trifocals
  • Oversized Lenses/Deluxe Frames
  • Polycarbonate Lenses
  • Tints
  • Initial refraction exams 
  • Special Requirements
  • Unlisted Procedures 
  • Claims Billing Guidelines 
  • Crossover Eyeglass Claims Requiring EOMB
  • Modifiers
• Optometric Procedure Codes (see pages 9-31 in the manual here)
  • Surgical Procedures
  • Evaluation and Management Codes (92002-92284)
  • Evaluation and Management Codes (92285-99215)
  • Frames  
  • Single Vision
  • Bifocals
  • Trifocals
  • Prosthetic Eye
  • Other Lens
  • Tints
  • Miscellaneous Codes

Claim Preparation Instructions

CMS 1500 Form Filing Instructions 
Vision Services - CMS 1500 Claim Form 

Error Status Codes

ESC Code List (English) 

Explanation of Benefits (EOB) Codes

EOB Codes and Messages List (English) 
EOB Codes and Messages List (Spanish)

Appendix - Third Party Liability Carrier and Coverage Codes

Third Party Liability (TPL) Carrier Codes 
Third Party Liability (TPL) Coverage Codes

For specific questions you may contact the Customer Service Help Desk at (401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll callers and border communities.