Insurance Company Policies on Referrals and Vision Care

University Children’s Eye Center participates in many insurance plans, including HMO, POS, and PPO plans. Most plans require that you obtain authorization from your primary care physician (PCP) before specialist visits are covered. Be sure to bring your insurance card, co-payment, and the appropriate referral form or authorization number to your appointment.

Please refer to the list below for specific information on your insurance company.

NOTES:

This list is given for informational purposes only. Insurance companies may change these requirements at any time. Contact your insurance company for the details governing your health insurance contract requirements and coverage.

Please note that a referral by your PCP does not ensure that a given service is a covered benefit. A referral is only an authorization from your PCP. For example, if your plan does not cover routine eye exams, the referral cannot be used.

Will my insurer pay for my child's routine eye exam?

Although our doctors do a comprehensive ophthalmic exam on all new patients, many insurance policies do not cover eye exams for refractive error only.
If the patient has myopia, astigmatism or other refractive error diagnosis, insurers pay for the comprehensive eye exam ONLY IF your plan has vision care coverage.
In the majority of cases, routine eye exams are on a self-pay basis only.
Sometimes employers purchase vision care benefits through vision care networks such as Davis, Metropolitan, VSP, etc. UCEC does not participate with any vision care network.
Please refer to the insurance list for more details or contact your insurer.

Aetna/USHC: Referrals: HMO and POS patients require referrals. Referrals are valid for one year, but the first visit must be used within 90 days.

Routine vision care:

· Check with carrier. Referral required to come to our office.

· AT&T or Lucent employees have vision care coverage through Metropolitan. Self pay at UCEC or use a Metropolitan provider.

AmeriChoice: Referrals: A handwritten referral from a PCP (script) is required.

Routine vision care: Not covered at UCEC. Must use vision care network or self-pay at UCEC.

AmeriHealth: Referrals: HMO plans require referrals. Referrals are valid for 90 days.

Routine vision care: Not covered at UCEC. Must use vision care network or self-pay at UCEC.

Consumer Health Network (CHN):

Referrals: None required.

Routine vision care: Check with carrier.

CIGNA: Referrals: CoMed and HMO patients must have a handwritten referral from a PCP (script).

Routine vision care:

· Cigna HMO patients: Check with carrier. Most if not all patients, can self-refer to a VSP provider or self-pay at UCEC.

· Cigna CoMed and PPO patients: Self-pay for most contracts. Check with carrier.

Empire: Referrals: HMO plans require referrals, which are valid for 90 days.

PPO patients do not require a referral.

Routine vision care: Check with carrier. Self-pay in the majority of cases.

First Health: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

Guardian: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

HealthCare Payers: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

HealthNet: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier

Horizon BCBS: Referrals: Required for HMO, NJPlus, and POS plans. Referrals are valid for 180 days.

Routine vision care:

· Horizon HMO and NJ patients are entitled to one exam per year without a referral.

· For most other Horizon plans, vision care is self-pay. Check with your carrier.

Horizon NJ Health: (Formerly Horizon Mercy)

Referrals: Required for all services. Referrals are valid for up to 180 days.

Routine vision care: Not covered at UCEC. Must use vision care network or self-pay at UCEC.

Mastercare: Referrals: Only the HMO plans require a referral. Make sure the referral was issued within 180 days of your appointment.

Routine vision care: Self pay in the majority of cases. Check with carrier.

Magnacare: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

Medicaid (SSI): Referrals: No referral required.

Routine vision care: Check with our office.

Medicare: Referrals: No referral required.

Routine vision care: Not applicable. In our office we only see adults with strabismus or diplopia.

Medichoice: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

Multiplan: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

One Health: Referrals: The majority of One Health plans do not require a referral. A small number of plans require a script from the patient’s primary care physician.

Routine vision care: Self pay in the majority of cases. Check with carrier.

Oxford: Referrals: Required for HMO plans.

Referrals are valid for 6 months. They must be made out to the doctor you are seeing.

If you have the PPO plan, a referral is not required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

Partners In Care: Referrals: Required for medical services. They are valid for 6 months.

Routine vision care: One exam per year. No referral is required for a routine eye examination.

PHCS: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

QualCare: Referrals: No referral required.

Routine vision care: Self pay in the majority of cases. Check with carrier.

United HealthCare: Referrals: The majority of United HealthCare plans do not require a referral. A small number of plans require a script from the patient’s primary care physician.

Routine vision care: Self pay in the majority of cases. Check with carrier.

University Health Plans (UHP):

Referrals: No referral required.

Routine vision care: Not covered at UCEC. Must use vision care network or self-pay at UCEC.

This information was updated on 5-16-03 and is correct to the best of our knowledge. Please contact your insurer for the most accurate and up to date information on your specific plan and benefits coverage.