Point32Health would like to offer some reminders to provide clarity around the correct billing practices for vision claims for Harvard Pilgrim Health Care and Tufts Health Plan members, to help ensure that these claims are reimbursed appropriately.
When billing for Harvard Pilgrim Commercial or StrideSM (HMO)/(HMO-POS) Medicare Advantage members, all claims for routine or nonroutine medical services provided by an optometrist or ophthalmologist should be submitted directly to Harvard Pilgrim via the typical claim submission processes.
However, the vision claim billing practices for Tufts Health Plan members vary depending on the member’s plan, the type of vision service, and the type of encounter.
When billing for Tufts Health Plan Commercial, Medicare Preferred, and Senior Care Options members:
- Submit claims for routine eye and optometry medical services to EyeMed Vision Care, our vision benefit administration vendor.
- Submit claims for ophthalmology medical services and imaging services directly to Tufts Health Plan via the typical claim submission process.
When billing for Tufts Health Direct, Tufts Health RITogether, and Tufts Health Unify members:
- Ophthalmologists and optometrists providing routine eye services or dispensing eyewear to these members should submit claims to EyeMed.
- Ophthalmologists and optometrists providing nonroutine medical eye services should submit claims directly to Tufts Health Plan.
For Tufts Health Together members, Tufts Health Plan provides reimbursement for eye examinations and MassHealth reimburses for eyeglasses, contact lenses, and other visual aids. Call MassHealth at 800.841.2900 for more information.
For additional information, refer to the following payment policies, which vary by product:
- Harvard Pilgrim’s Vision Services Payment Policy for Commercial and StrideSM (HMO)/(HMO-POS) Medicare Advantage products
- Tufts Health Plan’s Vision Services Professional Payment Policy for Commercial, Medicare Preferred, and Senior Care Options products
- Tufts Health Plan’s Vision Services Payment Policy for Public Plans products
Director, Provider Relations & Communications
Senior Manager, Provider Communications
Joseph O’Riordan, Jesse Salvato, Stephen Wong