Stamford Ophthalmology is proud to accept most medical insurance plans. Our staff will be happy to assist you in submitting and processing your claims, however, it is ultimately your responsibility to know what your own medical or vision plan covers. Please check your policy to determine your coverage prior to your exam. You may contact our billing office 203-327-5808 prior to your visit if you have any concerns or questions about the plans we cover.
Medical Plans Accepted:
- Anthem (Blue Cross/Blue Shield)
- GHI (except NY)
- Harvard Pilgrim
- Humana, Humana Gold
- United Healthcare
- United Healthcare Medicare Advantage Plan
Vision Plans Accepted (Dr. Pribis only / ROUTINE EXAMS ONLY):
Will my exam be covered by insurance?
Most eye exams, whether for a specific eye problem or for general vision care, will be covered at least in part by your primary medical insurance. As with any medical visit, your usual copays and deductibles will apply. Some services, including refraction and contact lens exams, may not be covered.
For insurance purposes, eye examinations are classified as either “Medical” or “Routine.” Your medical history, current symptoms, and examination findings will determine how your visit is coded.
What is a “Medical” eye exam?
Your visit will be coded as a medical exam if any of the following apply:
- You have any symptoms related to the health of the eyes, such as headaches, eye pain, itching, tearing, redness, dry eye, sudden vision changes, double vision, light sensitivity, floaters, etc.
- You have a known medical eye condition, such as cataracts, glaucoma or macular degeneration or you have a family history of glaucoma
- You have a history of diabetes, high blood pressure, or certain other medical diseases
- You are diagnosed with a medical eye condition during your exam
During a medical eye examination, the doctor will evaluate the reason for your symptoms and determine if any treatment or additional testing is required.
What is a “Routine” eye exam and will my insurance cover it?
If none of the above apply to you, this constitutes a routine “well-vision” exam. During a routine exam, your eyes will be examined for any needed visual correction (glasses, etc.) and screened for potential indicators of eye disease.
Please be aware that many insurance plans do not cover “routine” eye exams and will only cover your exam if you have medical symptoms related to the eyes or you are diagnosed with a medical eye condition.
Some insurance plans will cover a routine exam once every 1 or 2 years, depending on the policy.You must notify our staff in advance of your exam if your plan will cover a “routine” eye exam. If you are unsure, we recommend that you check with your insurance company prior to your exam. Once we submit a claim, it cannot be changed from medical to routine or vice versa.
Refraction: What is it and does my insurance cover it?
Refraction is the diagnostic procedure used to determine your best-corrected vision. This can be achieved at all ages using different techniques, but usually involves looking through a device with adjustable lenses while the doctor has you read letters on an eye chart. Refraction must be performed in order for the doctor to prescribe glasses. For some medical conditions and for most children who have been referred after a failed vision screen, refraction is needed even if glasses are not prescribed. Unfortunately, the majority of insurance companies (including Medicare) do not cover this essential procedure. If your insurance does not cover refraction, you will be billed accordingly. The current fee for refraction is $85 (subject to change) and is due on the day of service.
Does Stamford Ophthalmology accept Vision Plans?
We do not participate with most vision plans; however, Dr. Pribis does accept EyeMed for “routine” eye examinations only. If you have any medical symptoms related to the eyes, or if the doctor diagnoses any medical condition during your exam, your claim must be processed through your regular medical insurance. You may inquire at the optical shop to see if your vision plan can help cover the cost of glasses.
Will insurance cover my contact lens examination?
Medical insurance plans do not consider contact lenses medically necessary and will not typically cover contact lens fittings or annual contact lens examinations. Please review our contact lens agreement for details regarding our fees and policies.
What if I don’t have any medical insurance?
If you do not have any medical insurance, payment for any services provided is expected in full on the day of your visit. You may inquire with our staff regarding approximate fees.
Before Your Appointment Checklist
If you have an appointment with a Stamford Ophthalmology doctor, please review the following checklist prior to your visit:
- Determine whether or not your individual insurance policy covers eye examinations, and whether or not a referral or authorization for the examination is required. Many primary care physician offices require 24 to 48 hours in advance to generate an insurance referral, and in most cases referrals will not be generated retroactively. Please note that a consultation request from your medical doctor to see a doctor of Stamford Ophthalmology is separate from an Insurance Referral Authorization. If you have an insurance authorization for an eye examination, make sure that the appointment is scheduled within the required time frame (usually 30 to 90 days).
- Insurance copays, refraction fees and fees for any other non-covered services are due at the time of service.
- If you do not have medical or vision coverage, payment will be due at the time of service. You may call our billing office at 203-327-5808 for information on approximate fees.
- Please note that failure to provide 24 hours of notice of appointment cancellation may result in a $75 cancellation charge.
- Be sure to bring your current glasses, contact lenses, and contact lens information (manufacturer boxes or packages) with you on the day of your exam.
If your primary language is not English, language assistance services are available to you, free of charge. Call: 203-327-5808
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