Centene Vision Services is a leader in exceptional, tailored vision benefits and services for Medicaid, Medicare, and Marketplace member products. Every quarter we share key news that you can use to best serve your patients.

Double Billing: Avoid Duplicate Claims

As a reminder, submitting a claim for payment to both a health plan and Centene Vision — also known as double billing — for the same vision service is not permitted and may be considered fraudulent. Centene Vision monitors billing practices, and if duplicate claims are identified, the health plan and/or Centene Vision Services may take corrective action, including termination of the provider’s Participating Provider Agreement.

Share Your Feedback: Provider Survey Now Open

The annual Provider Satisfaction Survey has been emailed to all provider offices. Your feedback helps us better understand how we are doing and where we can improve.

We encourage you to share input on credentialing, customer service, utilization management, claims, care coordination, quality of care and overall experience.

Surveys were sent to the email address on file for your office. Please check your spam or junk folders, as the email will come from an external source (Qualtrics). We look forward to hearing from you!

Local Market News

Below is an important reminder for Louisiana:

Following the passage of Louisiana SB 404, Centene Vision Services is preparing for a provider agreement update that will begin in the coming months. We look forward to working with providers and will share additional details before any action is required.

Requirement Change: DEA License or CDS Certificate Required for Ophthalmologists

Effective June 1, 2026, all ophthalmologists (MD, DO) must have a current Drug Enforcement Administration (DEA) license and/or Controlled Dangerous Substance (CDS) certificate on their Council for Affordable Quality Healthcare (CAQH) profile, as applicable.

If a DEA license or CDS certificate is not available, providers must update their CAQH profile to include a written prescribing protocol or waiver.

Please note:

• Credentialing cannot be completed without one of these items on file.
• Providers who do not meet this requirement will not be eligible to render services.

To avoid delays or disruptions, ensure your CAQH profile is up to date with the required documentation.

Correct Coding Education: Comprehensive vs. Intermediate Eye Exam

Intermediate and comprehensive ophthalmological services are integrated services. This means:

• Medical decision-making cannot be separated from the examining techniques used.
• Individual exam components (e.g., slit lamp exam, keratometry, ophthalmoscopy, retinoscopy, tonometry, motor evaluation) should not be itemized or billed separately.

Comprehensive Eye Exams (92004, 92014)

Comprehensive ophthalmological services describe a general evaluation of the complete visual system.

• Always include initiation of a diagnostic and treatment program.

When to Use Intermediate Eye Exam Codes (92002, 92012)

Use intermediate exam codes when:

• Services are reported solely with refractive diagnoses, and
• There are no complicating comorbidities requiring initiation of a diagnostic or treatment program.

What Counts as “Initiation of a Diagnostic and Treatment Program”?

This includes:

• Prescribing medication
• Arranging for:
  • Diagnostic or treatment services
  • Consultations
  • Laboratory procedures
  • Radiological services

Additional Note

• Prescription of lenses, when required, is reported under 92015.
• This includes specification of lens type, power, axis, prism, absorptive factor, impact resistance, and other factors.

What the Retina Can Reveal About Cardiovascular Health

Retinal findings may offer important insight into a patient’s cardiovascular health. Several conditions identified during routine eye exams are associated with increased risk of stroke, myocardial infarction (MI), and other cardiovascular disease (CVD).

Central retinal artery occlusion (CRAO) is associated with significantly elevated risk of acute stroke, MI, and long-term cardiac conditions such as atrial fibrillation. Central retinal vein occlusion (CRVO) has also been linked to increased risk of stroke and MI. Cotton wool spots, often associated with diabetes and hypertension, are tied to higher risk of stroke- and heart-failure-related events. Additionally, patients with macular degeneration—particularly those with subretinal drusenoid deposits (SDD)—may have increased risk of ischemic stroke and MI.

Advances in imaging further highlight this connection. Findings such as a decreasing artery-to-vein ratio on fundus photography, reduced retinal or choroidal thickness on OCT, and changes in vessel density on OCTA have been associated with cardiovascular dysfunction. However, these biomarkers are nonspecific and require further validation before being used for routine screening or clinical decision-making.

Retinal findings can support a more comprehensive view of a patient’s health. When appropriate, consider discussing these findings with patients and encouraging follow-up with their primary care provider. These conversations can help patients better understand the connection between eye health and overall health and support timely evaluation of potential cardiovascular risk.

Source: NIH - Retinal Findings and Cardiovascular Risk: Prognostic Conditions, Novel Biomarkers, and Emerging Image Analysis Techniques

Always Check Member Eligibility

It is essential to review member eligibility before providing any services. This practice ensures that the services rendered are appropriately covered by the member’s health plan, reducing potential reimbursement issues and ensuring compliance with regulations. Maintaining an eligibility verification process helps both providers and members. You can verify eligibility online through Eye Health Manager or by calling Customer Service.

Stay Compliant: Avoid Common FWA Issues

Centene Vision Services conducts regular audits and uses systems to analyze claims to identify possible Fraud, Waste and Abuse (FWA). If any FWA is detected, the Centene Vision Special Investigation Unit will conduct a review that may result in actions against those who are found to have committed FWA. Actions may include:

• Provider education
• More rigorous Utilization Review requirements
• Recovery of monies previously paid
• Extrapolated overpayment calculation
• Reporting to appropriate payor and/or regulatory agencies (OIG)
• Termination from the Centene Vision Network

The most common submissions of FWA:

• Unbundling of codes
• Upcoding
• Misrepresentation of services
• Claims for services not rendered

If you suspect another provider is inappropriately billing Centene Vision Services or if a member is receiving unnecessary services, please contact Centene Vision Services Fraud, Waste and Abuse hotline as indicated below. We take all reports of potential FWA seriously and investigate all reported issues.

Improve the Health of Diabetic Members

Help your patients with diabetes and reduce administrative burdens. Centene Vision Services offers a dedicated HEDIS Training and Tips website to determine CPT II and other supplemental codes to use for diabetic retinal exams. Routine retinal evaluation is recommended to reduce the risk of diabetes-related blindness.

You may be eligible for a $10 CPT II reporting incentive. Please ensure your billing staff submits a billed rate of at least $10 to receive the maximum reimbursement for this incentive program. Review your fee schedule and remember to submit the appropriate CPT II codes referenced at HEDIS Training and Tips.

REMINDER: Glaucoma disproportionately affects Black and Hispanic individuals. They are more likely to develop vision loss and experience blindness from glaucoma than White individuals.

Is Your Practice Accessible?

To enhance the availability of healthcare services for individuals with disabilities, we invite you to participate in the Provider Accessibility Initiative (PAI) survey. It is vital that patients have the most accurate information about your practice’s accessibility.

Your involvement is particularly helpful to those patients who already struggle with many health care issues. According to the CDC, approximately one in four adults in the United States has a disability. Individuals with disabilities are more likely to:

• Have depression
• Struggle with obesity
• Have diabetes
• Smoke
• Have heart disease

Improving access to care for these at-risk patients is more important than ever. Please complete this short PAI survey to help make sure our members can find your practice when they need you most.

No Referral Needed

When scheduling eye exams for patients, referrals from primary care physicians (PCPs) are not required when seeing a participating optometrist or ophthalmologist.

Questions? Please contact Customer Service.

Member Transportation Services

Non-emergency transportation is a covered benefit for eligible members when traveling to medically necessary services. Members seeking transportation assistance should review their health plan’s member handbook to determine whether coverage is available and contact the listed transportation provider in advance to schedule a ride.

Vision Care by the Numbers

About Us

A subsidiary of Centene for more than 30 years, Envolve Benefit Options, doing business as Centene Vision Services, has partnered with vision care providers across the country to administer eye care programs that meet the needs of our members. You are among 26,000+ unique eye care providers, including independent providers and popular retail chains, within our network. Thank you for partnering with us to provide quality vision services to your patients.