OptiCodeVision Insurance Billing: VSP, EyeMed, and Medical vs. Vision Plans
Optometry is one of the few medical specialties that routinely deals with two separate insurance systems: vision plans and medical insurance. Understanding when to bill each — and how major vision plans like VSP and EyeMed work — is essential for accurate billing and avoiding costly denials.
Medical vs. Vision Insurance: The Core Distinction
The most fundamental billing decision in an optometry practice is whether an encounter should be billed to a medical insurance plan or a vision plan. This depends entirely on the nature of the visit.
Vision plans (VSP, EyeMed, Spectera, Davis Vision) are designed to cover routine eye care — refractive exams, contact lens fitting, and optical materials like frames and lenses. They are wellness benefits, not medical benefits.
Medical insurance (Aetna, BCBS, Cigna, UnitedHealthcare, Medicare, Medicaid) covers medically necessary eye care — diagnosis and management of conditions like glaucoma, diabetic retinopathy, cataracts, macular degeneration, and dry eye disease.
| Aspect | Vision Plan | Medical Insurance |
|---|---|---|
| Type of services | Routine vision care (refractions, exams, optical) | Medical eye conditions (glaucoma, diabetes, cataracts) |
| Exam codes | Often plan-specific (VSP portal codes, or 99XXX with vision modifier) | CPT 92004, 92012, 92014, 99213, 99214 |
| Diagnosis codes | Refractive errors (H52.x), Z01.00 (screening) | Medical diagnoses (H40.x, E11.x, H25.x, H35.x) |
| Materials | HCPCS V-codes for frames, lenses, contacts | Typically not covered (optical) — or A-codes for supplies |
| Payer ID | VSP (39026), EyeMed (62308), Spectera, Davis | Medical payer — Aetna, Cigna, BCBS, Medicare, Medicaid |
Major Vision Plans in Optometry
VSP Vision Care
One of the largest vision plans in the U.S. VSP is a provider-owned cooperative. Practices contract directly with VSP to see VSP members. VSP uses its own fee schedules and claim submission portal (Eyefinity/VSP Online), though electronic claims can also be submitted through some clearinghouses.
Billing Notes
VSP claims are typically submitted through the VSP portal or an integrated PM system. VSP uses HCPCS codes for optical materials. Exam codes differ from standard CPT depending on your VSP contract.
Common Payer ID: 39026
EyeMed Vision Care
EyeMed is a vision benefit plan owned by Luxottica. It is widely offered through employer group health plans. EyeMed offers both "in-network" benefits (through their access plan network) and "out-of-network" reimbursement.
Billing Notes
EyeMed electronic claims are submitted to payer ID 62308 through most major clearinghouses. EyeMed uses a fee schedule for covered services and provides explanation of benefits (EOBs) electronically via 835 ERA.
Common Payer ID: 62308
Spectera Eyecare Networks
Spectera is UnitedHealthcare's vision subsidiary, offering vision benefits to UHC commercial members. It covers routine eye exams, frames, lenses, and contact lenses at the routine care level.
Billing Notes
Spectera claims route through UnitedHealthcare's clearinghouse infrastructure. Verify the correct payer ID for Spectera vs. standard UHC medical claims, as they differ.
Common Payer ID: Various — use OptiPayer™ to confirm
Davis Vision
Davis Vision offers managed care vision benefits primarily through employer groups on the East Coast. Davis Vision has merged operations with Versant Health under MetLife's vision portfolio.
Billing Notes
Davis Vision / Versant Health electronic claims go through Emdeon/Change Healthcare. Verify the current payer ID, as routing has changed with ownership transitions.
Common Payer ID: Confirm with OptiPayer™
Tip: Payer IDs change. Always verify the current electronic payer ID before submitting claims to any vision plan. Use OptiPayer™ to look up accurate payer IDs for VSP, EyeMed, and hundreds of other vision and medical plans.
Common Vision Billing Mistakes
✗Billing a routine refraction to medical insurance
Most medical insurance plans — including Medicare — do not cover routine refractions (92015). Billing a refraction to medical when only a vision plan covers it results in a denial or patient liability.
✗Billing a medical diagnosis to a vision plan
Vision plans cover routine care. If a patient has a medical condition like glaucoma or diabetic retinopathy, that encounter should be billed to the medical plan — not the vision plan.
✗Using the wrong payer ID
Vision plans often have different payer IDs than the patient's medical plan. Using the medical insurance payer ID for a VSP or EyeMed claim routes the claim to the wrong place.
✗Billing both vision and medical for the same exam
Splitting a single encounter to bill both a vision plan and a medical plan (for different parts of the exam) requires careful documentation and compliance with the plans' policies. Coordination of benefits rules apply.
✗Not verifying vision vs. medical benefits before the visit
A patient may have both vision and medical benefits, or only one. Confirming which benefits apply — and which is primary for the anticipated services — prevents billing to the wrong plan.
Related Resources
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