What insurance policy changes affect Optometry providers?

Optometry providers face policy updates from major payers including prior authorization requirements, billing code changes, reimbursement rate adjustments, and coverage criteria revisions. PolicyChanges.app tracks these updates daily across all major insurers.

How often do insurance policies change for Optometry?

Insurance payers publish policy changes on rolling schedules: some quarterly, some monthly, and some with immediate effect. Optometry practices typically see dozens of relevant changes per year across their contracted payers.

How do I get notified of new Optometry policy changes?

Sign up for a free PolicyChanges.app account and create a saved search filtered to Optometry. You will get an email when new policy changes match your specialty filter: daily or weekly, your choice, on every plan.

Which payers post the most policy changes affecting Optometry?

Based on tracked changes, Optometry updates have come from payers including MassHealth, Medicare/CMS, Anthem BCBS.

PAYER POLICY CHANGES

Optometry Insurance Policy Changes

Keeping up with insurance policy changes that affect Optometry practices is a full-time job. This page aggregates the latest payer updates (prior authorization rule changes, reimbursement adjustments, billing code additions and removals, and coverage policy revisions) across all major insurers. Changes are identified and summarized daily so Optometry providers and their billing teams can act before deadlines pass.

MassHealth · Effective Jan 1, 2027High impact
All Provider Bulletin 421: Enrollment Requirement for All Providers on Claims Submitted to MassHealth - Corrected
Effective January 1, 2027, MassHealth will require all ordering, referring, prescribing, attending, supervising, and operating (ORPASO) providers on claims to be enrolled with MassHealth on the date of service (or within 90 days after first date of service for ordered/referred/prescribed services). Claims with unenrolled providers in these roles will be denied. MassHealth is currently sending informational denial messages to prepare providers for this enforcement.
Medicare/CMS · Effective Jan 1, 2027High impact
2026-07-16 - CY 2027 Medicare Physician Fee Schedule Proposed Rule
CMS issued a proposed rule for CY 2027 Medicare Physician Fee Schedule with multiple payment and policy changes effective January 1, 2027, including modifications to E/M visit billing, ACO participation requirements, Quality Payment Program updates, and new HCPCS codes for home health consolidated billing and hospice telecommunications. Additionally, optometry services billing at nursing facilities must be corrected to avoid improper E/M code usage, and new hepatitis C screening code G0567 is now payable.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[New York] Precertification/prior authorization list change notification
Anthem Blue Cross and Blue Shield is adding five CPT codes and one HCPCS code related to Dichoptic Digital Therapy for Amblyopia to their prior authorization requirements, effective January 1, 2027. All services using codes 0687T, 0688T, 0704T, 0705T, 0706T, and A9292 will now require precertification before service delivery to ensure coverage eligibility and compliance with clinical guidelines.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Virginia] Precertification/prior authorization list change notification
Effective January 1, 2027, Anthem Blue Cross and Blue Shield (Virginia) is adding Dichoptic Digital Therapy for Amblyopia (CPT codes 0687T, 0688T, 0704T, 0705T, 0706T, and HCPCS A9292) to its precertification/prior authorization requirements. Providers must obtain prior authorization before rendering these services or claims may be denied as ineligible for payment.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Georgia] Precertification/prior authorization list change notification
Effective January 1, 2027, Anthem Blue Cross and Blue Shield in Georgia is adding five CPT codes (0687T, 0688T, 0704T, 0705T, 0706T) and one HCPCS code (A9292) for Dichoptic Digital Therapy for Amblyopia to their precertification/prior authorization requirements under clinical criteria CG-MED-102. All services using these codes will require prior authorization before delivery to avoid claim denials.
NC Medicaid - NCDHHS · Effective Nov 1, 2026High impact
Quarterly Provider Update – Summer 2026
NC Medicaid will begin verifying active DEA certification for prescribers on controlled substance claims effective November 1, 2026. Claims for controlled substances will be denied if the prescriber lacks an active DEA number in NCTracks. Additionally, providers must complete multiple compliance actions by specific deadlines, including 251S00000X taxonomy providers adding services by October 1, 2026, behavioral health organizations confirming national accreditation status, and high-risk providers preparing for expedited off-cycle reverification.
NC Medicaid - NCDHHS · Effective Nov 1, 2026High impact
Action Required: Drug Enforcement Administration Certification Required for Prescribing Controlled Substances
NC Medicaid now requires prescribers to have an active DEA certification on file in NCTracks before controlled substance claims will be adjudicated. Beginning November 1, 2026, pharmacy claims for controlled substances will be denied if the prescribing provider lacks an active DEA number in their NCTracks provider enrollment record. Billing teams must ensure all prescribing providers have DEA certifications documented in NCTracks by this deadline.
Indiana Medicaid (IHCP) · Effective Oct 28, 2026High impact
BT2026155: IHCP updates billing requirements for specific waiver services and specific vision services
IHCP implements two new billing restrictions effective Oct. 28, 2026: (1) Claims for waiver services T2033, S5151, and T2016 will be denied if billed with modifier HQ and POS code 12 (Home), and (2) V2755 (ultraviolet lens treatment) will be paid at $0 when billed with V2784 (polycarbonate lenses) unless V2755 has a diagnosis code outside the Refractive Error group. Billing teams must validate modifier/POS combinations for waiver services and diagnoses for vision claims before submission.
Alabama Medicaid · Effective Oct 1, 2026High impact
Removal of Medicare and TPL Exemption
Effective October 1, 2026, Alabama Medicaid is removing the exemption that allowed optometrists and opticians to file claims directly with Medicaid. Providers must now file with the beneficiary's primary insurance (including Medicare) before submitting claims to Medicaid. This represents a shift to mandatory primary-secondary claim filing sequencing.
Wisconsin Medicaid (ForwardHealth) · Effective Jul 13, 2026High impact
Prior Authorization Process Improvements: Revising the Prior Authorization Request Form, Vision Procedure Codes, and Prior Authorization RequirementsApril 17, 2026: This Update has been revised since its original publication. Information regarding the dental and orthodontic exception for PA requests requiring physical 3D models has been corrected on page 1 and 2.
Wisconsin Medicaid stopped requiring prior authorization (PA) for seven vision procedure codes beginning April 13, 2026. Beginning July 13, 2026, providers must submit PA requests electronically on the ForwardHealth Portal, and ForwardHealth will no longer accept PA requests by fax or mail, except for pharmacy PA submissions and dental or orthodontic 3D models. ForwardHealth also adopted a universal backdating policy for initial PA requests, and it removed the Returned-Provider Review PA status, so incomplete non-drug PA requests are denied rather than returned.
Wisconsin ForwardHealth · Effective Jul 13, 2026High impact
ForwardHealth Update 2026-09: Prior Authorization Process Improvements: Revising the Prior Authorization Request Form, Vision Procedure Codes, and Prior Authorization RequirementsApril 17, 2026: This Update has been revised since its original publication. Information regarding the dental and orthodontic exception for PA requests requiring physical 3D models has been corrected on page 1 and 2.
ForwardHealth (Wisconsin Medicaid) is eliminating fax and mail prior authorization submissions effective July 13, 2026, requiring all PA requests be submitted electronically through their Portal. The policy also implements a universal 14-day backdating policy and removes certain vision procedure codes from PA requirements.
Indiana Medicaid (IHCP) · Effective Jul 2, 2026High impact
BT2026114: IHCP clarifies FQHC and RHC billing procedures for vision services
IHCP clarifies billing procedures for vision services at FQHCs and RHCs, requiring all vision services to be billed on professional claims with HCPCS code T1015 and a valid encounter code. When eyeglasses are picked up on a separate date from the eye exam, providers have two options: submit one combined claim (eligible for PPS rate) or submit separate claims for exam and materials (materials-only claim must be denied). Materials are limited to basic frames and lenses; upgrades and non-medically-necessary contact lenses are member responsibility with advance notification required.
Connecticut Medicaid (HUSKY Health) · Effective Jul 1, 2026High impact
2026.34 - Provider Bulletin - Rate Increases to Select Procedure Codes for Optometry Services
Connecticut Medical Assistance Program (CMAP) is increasing reimbursement rates for eight optometry procedure codes effective July 1, 2026. The rates for these codes will now match physician reimbursement rates under CMAP. Billing teams must update fee schedules in their billing systems to reflect the new rates for CPT codes 92004, 92014, 92015, and 92250 with applicable modifiers.
Alabama Medicaid · Effective Jun 30, 2026High impact
Alabama Medicaid 2026 Off-Cycle Revalidation
Alabama Medicaid is conducting off-cycle provider revalidations effective 6/30/2026, with two tracks: swift revalidation for high-risk providers (DME, Home Health, Hospice, Nursing Facilities, ABA, Behavioral Health) and 24-month revalidation for moderate/limited-risk providers (33 provider types including hospitals, physicians, pharmacies, clinics). Providers will receive phased revalidation notices and must respond timely via the Medicaid Secure Web Portal or face enrollment termination.
CareSource · Effective May 1, 2026High impact
[Indiana] Routine Vision Benefits
Effective May 1, 2026, CareSource is transitioning routine vision benefit administration from Versant/Superior Vision to EyeMed for all Indiana Medicaid members. Billing teams must route claims to EyeMed (P.O. Box 8504, Mason, OH 45040; EDI Payer ID 31165) for dates of service on or after May 1, 2026, while continuing to submit pre-May 1 claims to Versant/Superior Vision. Medical vision benefits remain with CareSource.
Aetna · Effective Jan 14, 2026High impact
Age-Related Macular Degeneration (CPB 0765, reviewed 2026-01-14)
Aetna's refreshed CPB 0765 policy (effective 2026-01-14) clarifies coverage for Age-Related Macular Degeneration treatments, including six FDA-approved anti-VEGF therapies and photodynamic therapy for wet ARMD, while explicitly listing 40+ diagnostic tests and experimental interventions as non-covered. Billing teams must immediately update denial protocols to reject claims for genetic testing (SNP panels, CFH polymorphism), OCT biomarker analysis, ForeseeHome monitoring codes, and photobiomodulation therapies, while ensuring medical necessity documentation for covered injections meets specific criteria.
CareSource · Effective Jan 1, 2026High impact
[Ohio] Transition to EyeMed for Routine Vision Services
Effective January 1, 2026, EyeMed replaces Versant/Superior as the routine vision vendor for Ohio Medicaid and CareSource MyCare Ohio (HMO D-SNP). Vision providers must contract with EyeMed to deliver routine vision services to these members, while medical vision services still require CareSource contracts. Claims with service dates through December 31, 2025, will continue processing through the old vendors until December 31, 2026.
Kansas Medicaid (KanCare) · Effective Jun 1, 2025High impact
KMAP BULLETIN: Vision Services – “New Patient” Coding Guidelines
Starting June 1, 2025, KMAP will limit new patient vision evaluation codes 92002 and 92004 to once per three-year period across all providers within the same group practice, regardless of specialty. Any vision services within three years must be billed as established patient visits.
Horizon BCBS NJ · Identified Oct 3, 2026High impact
Tips for Using a Modifier with CPT Category II Quality Reporting Codes
Horizon Blue has clarified that adding modifiers 1P, 2P, 3P, or 8P to CPT Category II quality reporting codes disqualifies practices from receiving credit for quality measures. To receive credit for reviewed-but-not-performed services, report CPT Category II codes WITHOUT these modifiers. This applies to HEDIS reporting and NCQA guidelines.
Health Net · Identified Aug 27, 2026High impact
26-1022 Notify Health Net of Ownership, Tax Identification Number and Provider Information Changes
Health Net now requires ancillary providers to promptly notify them in writing of any changes affecting provider records or contracting information, including ownership changes, TIN/NPI updates, business name changes, address changes, site additions/closures, and phone number changes. Failure to notify Health Net will result in claims being denied, processed as out-of-network, or delayed until records are updated.
EmblemHealth · Identified Jun 20, 2026High impact
Do Not Collect Copays for Senior Care Members
EmblemHealth has suspended the $15 copay for City of New York retirees on the GHI Senior Care Plan for multiple services including office visits, urgent care, therapy services, and diagnostic testing. Billing teams must immediately stop collecting these copays for eligible members.
New Jersey Medicaid · Identified Jun 20, 2026High impact
Newsletter Vol. 2, No. 55
This policy defines covered and non-covered services for Medicaid recipients enrolled in HIP of New Jersey (an HMO) in Burlington, Gloucester, and Hudson counties. Key billing impact: claims for non-emergency HIP-covered services billed to members with restricted HMO cards will be denied with error code; emergency care authorization rules and benefit exhaustion procedures are outlined; dental, orthotics, hearing aids, prescription drugs, and family planning services are NOT covered by HIP and must be billed to Medicaid fiscal agent instead.
Colorado Medicaid · Identified Jun 20, 2026High impact
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600537 - 04/2026)
Colorado's April 2026 Health First Colorado provider bulletin (B2600537) reduces applicable fee-for-service rates to 85% of their Medicare benchmark effective April 1, 2026, and requires a qualifying ICD-10 diagnosis within the first four diagnosis code positions on outpatient remote patient monitoring claims effective April 1, 2026. Repeat initial inpatient or observation E/M codes 99221 through 99223 on the same date of service must be billed with modifier 77 when the repeat service is distinct and medically necessary. Hospital Specialty Drug claims must carry the NDC, the NDC units, the acquisition cost and a drug-specific invoice, and fee-for-service pharmacy claims moved to MedImpact effective April 1, 2026.
Independence Blue Cross · Identified Jun 19, 2026High impact
07.13.12d, Instrument-Based Vision Screening
Independence Blue Cross reissued policy 07.13.12d confirming that instrument-based vision screening (CPT 99174, 99177) is considered part of the Evaluation and Management service and is NOT eligible for separate reimbursement, whether billed alone or with other services. Providers cannot bill members for this service.
Medicare/CMS - LCD · Effective Nov 5, 2026Medium impact
Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy
CGS Administrators' LCD L33946 (Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy) sets limited coverage for post-cataract Nd:YAG capsulotomy and discission, covered only when documented criteria are met (decreased ADL function, best-corrected visual acuity of 20/50 or worse or specified consensual/glare testing drop, other eye disease excluded, physician concurrence, patient education, and preoperative evaluation). The source states the revision (R15, 11/05/2026) was an annual review with no changes and that the 10/30/2026 update does not restrict coverage, so the criteria themselves are not new. Billing teams should confirm their documentation and claim coding support these criteria, since claims lacking them will be denied under this LCD.
Medicare/CMS - LCD · Effective Oct 22, 2026Medium impact
Electroretinography (ERG)
CGS Administrators has updated Local Coverage Determination L38992 for Electroretinography (ERG), effective 2026-10-22. This update to the LCD may affect coverage criteria, documentation requirements, or billing guidance for ERG procedures under Medicare Part A and Part B in the CGS service area. The billing team should review the specific policy changes to determine impact on current ERG claim submission practices.
Medicare/CMS - LCD · Effective Oct 8, 2026Medium impact
Visual Fields Testing
Local Coverage Determination L34394 for Visual Fields Testing by CGS Administrators (MAC - Part A and Part B) becomes effective 2026-10-08. The billing team must review the full policy text to identify specific coverage requirements, billing codes, medical necessity criteria, and any prior authorization mandates applicable to visual fields testing claims submitted to this Medicare contractor.
Connecticut Medicaid (HUSKY Health) · Effective Oct 1, 2026Medium impact
2026.52 - Provider Bulletin - October 2026 Quarterly HIPAA Compliant Update-Physician Office and Outpatient Fee Schedule
Connecticut's HUSKY Health program is updating its physician office and outpatient fee schedule effective October 1, 2026, to incorporate October 2026 HCPCS code changes (additions, deletions, and description updates) for HIPAA compliance. Additionally, claims for HCPCS code J1818 (pegzilarginase-nbln injection) must now be submitted with ICD-10-CM diagnosis code E722.1 (Argininemia) or they will be denied.
Connecticut Medicaid (HUSKY Health) · Effective Oct 1, 2026Medium impact
2026.54 - Provider Bulletin - October 2026 Quarterly HIPAA Compliant Update-Laboratory Fee Schedule
Connecticut's CMAP is updating its Laboratory fee schedule effective October 1, 2026, to incorporate HCPCS code changes (additions, deletions, and description updates) for HIPAA compliance. Billing teams must download the updated fee schedule from ctdssmap.com to ensure accurate coding and reimbursement for laboratory services under HUSKY Health programs (A, B, C, D).
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Corneal Topography
UnitedHealthcare Medicare Advantage updated its Corneal Topography medical policy effective October 1, 2026, to reflect the most current CMS coverage documents and clinical evidence. The billing team must review the updated policy in the Medicare Coverage Database to identify any changes to coverage criteria, medical necessity requirements, or billing guidelines that may affect claim submissions.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
Glaucoma Surgical Treatments (for Kansas Only)
UnitedHealthcare Community Plan of Kansas (Medicaid) revised coverage for glaucoma surgical treatments effective October 1, 2026. Key changes: removed "some" language to expand glaucoma drainage device coverage for refractory glaucoma in adults; clarified that all other FDA-approved laser procedures not explicitly listed are unproven and not medically necessary. This affects prior authorization determinations and claim denials for unlisted laser procedures.
Ambetter · Effective Sep 1, 2026Medium impact
Ophthalmic Diagnostic Imaging Policy Revision: Effective September 1, 2026
Sunflower Health Plan (Centene/Envolve) revised its Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) policy effective September 1, 2026, clarifying medical necessity indications for anterior segment, optic nerve, and posterior retinal SCODI imaging. The policy explicitly excludes coverage for advanced glaucomatous damage and screening for glaucoma, requiring billing teams to implement denial protocols for these non-covered indications.
Ambetter · Effective Sep 1, 2026Medium impact
Update to Scanning Computerized Ophthalmic Diagnostic Imaging (CP.VP.14): Effective September 1, 2026
Ambetter from Peach State Health Plan updated its medical necessity policy (CP.VP.14) for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) effective September 1, 2026. The policy clarifies covered indications (anterior SCODI, posterior optic nerve SCODI, posterior retinal SCODI with and without OCT angiography) and explicitly excludes coverage for advanced glaucomatous damage screening and glaucoma screening. Billing teams must ensure claims for excluded indications are not submitted or will face denials.
Blue Cross Blue Shield of Rhode Island · Effective Sep 1, 2026Medium impact
Provider Notification: iDose TR (J7355) and Durysta (J7351)
Effective September 1, 2026, iDose TR (J7355) and Durysta (J7351) will require prior authorization under the medical benefit and are subject to Step Therapy, requiring documented trial and failure of topical prostaglandin analogs (e.g., Travoprost eye drops) before approval. This is a Blue Cross Blue Shield Rhode Island (BCBS RI) policy affecting these two glaucoma/ocular hypertension medications.
Medicare/CMS - Transmittals · Effective Aug 28, 2026Medium impact
R13889BP: Update to Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 110.8 Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Benefit Category Determinations
Section 110.8 of the Medicare Benefit Policy Manual is updated to reflect DMEPOS benefit category determinations for the 2025 biannual 1 and 2 Level II HCPCS coding cycles. Each listed code is assigned a benefit category, such as DME, Prosthetic Device, Back Brace, Leg Brace, Prosthetic (Artificial Leg or Arm), Lymphedema Compression Treatment Item, or No Medicare DMEPOS benefit category. This update makes no change in policy.
Missouri Medicaid (MO HealthNet) · Effective Aug 14, 2026Medium impact
Placement of Amniotic Membrane on the Ocular Surface; Without Sutures Coverage in the Optical Program
MO HealthNet now covers CPT code 65778 (Placement of Amniotic Membrane on the Ocular Surface; Without Sutures) in the Optical Program, effective August 14, 2026. The service requires pre-certification through CyberAccess and is only eligible for participants with qualifying ocular diagnoses and documented failed alternative therapies. Reimbursement rates are $1,034.55 for unilateral and $1,551.83 for bilateral procedures.
Missouri Medicaid (MO HealthNet) · Effective Aug 14, 2026Medium impact
CPT 65778 in Optical Program
Effective August 14, 2026, MO HealthNet now covers CPT 65778 (Placement of Amniotic Membrane on the Ocular Surface; Without Sutures) in the Optical Program for eligible participants with qualifying ocular diagnoses and documented failed alternative therapies. This service requires pre-certification through CyberAccess before delivery, with reimbursement rates of $1,034.55 (unilateral) or $1,551.83 (bilateral with modifier 50).
Humana · Effective Jul 1, 2026Medium impact
Ocular Surface Disease Diagnosis and Treatments - Medicare Advantage (Revised)
This Medicare Advantage policy (effective 07/01/2026) establishes updated coverage criteria for ocular surface disease (OSD) diagnosis and treatment procedures. The policy requires specific diagnostic testing (ocular surface staining, Schirmer test, tear osmolarity, etc.) and documented failure of conventional medical management before covering advanced treatments like amniotic membrane transplantation, punctal plugs, tarsorrhaphy, and surgical eyelid corrections.
Nevada Medicaid · Effective Jun 22, 2026Medium impact
Attention Provider Types 20 (Physician, M.D., Osteopath, D.O.), 25 (Optometrist), 41 (Optician, Optical Business): Age Restriction for Procedure Code V2760 Added in the Medicaid Management Information System (MMIS) to Match Policy
Nevada Medicaid has added age restrictions to procedure code V2760 (scratch resistant coating, per lens) in their billing system, effective June 22, 2026. This service is now limited to EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) recipients only, which means it's restricted to pediatric patients under age 21.
Capital Blue Cross · Effective Jun 1, 2026Medium impact
AB2026-06-002 Quality information
Capital Blue Cross updated HEDIS quality measure requirements for three diabetes-related screenings: eye exams (EED), glycemic status assessment (GSD), and kidney health evaluation (KED). This administrative bulletin clarifies documentation requirements, acceptable test types, and exclusion criteria for diabetic patients aged 18-85.
Humana · Effective Apr 22, 2026Medium impact
Cosopt® (dorzolamide and timolol ophthalmic solution) (Revised)
Humana revised its Cosopt (dorzolamide-timolol ophthalmic solution) coverage policy effective April 22, 2026. This is a step therapy policy for Medicare Advantage members requiring documentation of previous treatment or intolerance to dorzolamide/timolol before coverage is approved. The policy applies to all Cosopt formulations (brand name, preservative-free, and generic versions).
Independence Blue Cross · Effective Apr 20, 2026Medium impact
MA05.050c, Eye Prostheses and Scleral Cover Shell
Independence Blue Cross clarified medically necessary criteria for eye prostheses and scleral cover shells to align with CMS recommendations, effective April 20, 2026. The policy intent remains unchanged, but billing teams must ensure documentation meets updated standards for polishing/resurfacing (twice yearly), enlargements/reductions (first without documentation, additional requiring medical record support), and trial scleral cover shells (non-billable, included in final shell reimbursement).
Independence Blue Cross · Effective Apr 20, 2026Medium impact
05.00.83a, Eye Prostheses and Scleral Cover Shell
Independence Blue Cross updated Medical Policy 05.00.83a to clarify coverage criteria and benefits for eye prostheses and scleral cover shells, effective 04/20/2026. Key clarifications include: eye prosthesis coverage for absence/shrinkage due to birth defect, trauma, or surgical removal; polishing/resurfacing covered twice yearly; one enlargement or reduction covered without documentation, additional ones require medical necessity documentation; and scleral cover shells covered for sightless/shrunken eyes from inflammatory disease or severe dry eye. Documentation requirements remain consistent with Medicare standards, requiring timely provider orders and contemporaneous delivery confirmation.
Florida Blue · Effective Apr 1, 2026Medium impact
Accurate Documentation Optimizes Health Outcomes and More
Florida Blue emphasizes the importance of accurate documentation using specific CPT II and ICD-10 codes for HEDIS quality measures including statin therapy, diabetic eye exams, cancer screenings, and flu vaccinations. This policy focuses on proper coding and documentation practices to improve patient outcomes and HEDIS scores.
CareSource · Effective Mar 1, 2026Medium impact
[Indiana] Routine Vision Benefits
CareSource Indiana Medicaid is switching from Versant/Superior Vision to EyeMed for administering routine vision benefits effective March 1, 2026. Claims must be submitted to different systems based on service dates, with a new mailing address and EDI Payer ID.
Medicare/CMS · Effective Mar 1, 2026Medium impact
2026-02-12 - Short-Term Acute Care Hospitals: Staff End Users Can Now Access PEPPERs
CMS has made several updates including allowing hospital staff to access PEPPER reports, transitioning CLIA certificates to electronic-only format after March 1, 2026, and clarifying billing requirements for global surgery reporting and optometry services at nursing facilities.
CareSource · Effective Feb 1, 2026Medium impact
[Georgia] Versant Policies
CareSource Georgia Medicaid has partnered with Versant Health to provide vision services coverage. Two vision policies are being updated effective February 1, 2026: Policy 1309 (Medically Necessary Contact Lenses) and Policy 1330 (Specialty Spectacle Lenses). Billing teams must review the full policy text on the Versant website to understand coverage criteria and any billing requirements.
CareSource · Effective Feb 1, 2026Medium impact
[Georgia] Routine Vision Vendor Change to EyeMed Starting 2/1/2026
CareSource Georgia Medicaid is switching routine vision benefit administration from Versant/Superior Vision to EyeMed effective February 1, 2026. Billing teams must redirect all routine vision claims submitted on or after 2/1/2026 to EyeMed instead of Versant/Superior Vision. Providers must establish contracts with EyeMed to continue treating CareSource Georgia Medicaid members for routine vision services.
Blue Cross & Blue Shield of Mississippi · Effective Jan 20, 2026Medium impact
Corneal Collagen Cross-Linking
Corneal collagen cross-linking using riboflavin and ultraviolet A may be considered medically necessary as a treatment of progressive keratoconus or corneal ectasia resulting from refractive surgery in individuals who have failed conservative treatment, such as spectacle correction or rigid contact lens. It is considered investigational for all other indications. Photrexa products are planned to be discontinued from the market effective January 20, 2026, with manufacturing set to end February 2026. Epioxa was approved in 2025 for treatment of keratoconus in adults and children aged 13 years and older.
Indiana Medicaid (IHCP) · Effective Jan 12, 2026Medium impact
BT2025178: IHCP updates guidelines to allow optometrists to bill chalazion excision services
Indiana Medicaid (IHCP) is expanding coverage to allow optometrists to bill for chalazion excision services (removal of chronic eyelid growths) using CPT codes 67800, 67801, and 67805. This change applies to all IHCP programs including HIP, Hoosier Care Connect, and Traditional Medicaid, with no prior authorization required.

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All Provider Bulletin 421: Enrollment Requirement for All Providers on Claims Submitted to MassHealth - Corrected

2026-07-16 - CY 2027 Medicare Physician Fee Schedule Proposed Rule

[New York] Precertification/prior authorization list change notification

[Virginia] Precertification/prior authorization list change notification

[Georgia] Precertification/prior authorization list change notification

Quarterly Provider Update – Summer 2026

Action Required: Drug Enforcement Administration Certification Required for Prescribing Controlled Substances

BT2026155: IHCP updates billing requirements for specific waiver services and specific vision services

Removal of Medicare and TPL Exemption

BT2026114: IHCP clarifies FQHC and RHC billing procedures for vision services

2026.34 - Provider Bulletin - Rate Increases to Select Procedure Codes for Optometry Services

Alabama Medicaid 2026 Off-Cycle Revalidation

[Indiana] Routine Vision Benefits

Age-Related Macular Degeneration (CPB 0765, reviewed 2026-01-14)

[Ohio] Transition to EyeMed for Routine Vision Services

KMAP BULLETIN: Vision Services – “New Patient” Coding Guidelines

Tips for Using a Modifier with CPT Category II Quality Reporting Codes

26-1022 Notify Health Net of Ownership, Tax Identification Number and Provider Information Changes

Do Not Collect Copays for Senior Care Members

Newsletter Vol. 2, No. 55

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600537 - 04/2026)

07.13.12d, Instrument-Based Vision Screening

Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy

Electroretinography (ERG)

Visual Fields Testing

2026.52 - Provider Bulletin - October 2026 Quarterly HIPAA Compliant Update-Physician Office and Outpatient Fee Schedule

2026.54 - Provider Bulletin - October 2026 Quarterly HIPAA Compliant Update-Laboratory Fee Schedule

Corneal Topography

Glaucoma Surgical Treatments (for Kansas Only)

Ophthalmic Diagnostic Imaging Policy Revision: Effective September 1, 2026

Update to Scanning Computerized Ophthalmic Diagnostic Imaging (CP.VP.14): Effective September 1, 2026

Provider Notification: iDose TR (J7355) and Durysta (J7351)

R13889BP: Update to Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 110.8 Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Benefit Category Determinations

Placement of Amniotic Membrane on the Ocular Surface; Without Sutures Coverage in the Optical Program

CPT 65778 in Optical Program

Ocular Surface Disease Diagnosis and Treatments - Medicare Advantage (Revised)

Attention Provider Types 20 (Physician, M.D., Osteopath, D.O.), 25 (Optometrist), 41 (Optician, Optical Business): Age Restriction for Procedure Code V2760 Added in the Medicaid Management Information System (MMIS) to Match Policy

AB2026-06-002 Quality information

Cosopt® (dorzolamide and timolol ophthalmic solution) (Revised)

MA05.050c, Eye Prostheses and Scleral Cover Shell

05.00.83a, Eye Prostheses and Scleral Cover Shell

Accurate Documentation Optimizes Health Outcomes and More

[Indiana] Routine Vision Benefits

2026-02-12 - Short-Term Acute Care Hospitals: Staff End Users Can Now Access PEPPERs

[Georgia] Versant Policies

[Georgia] Routine Vision Vendor Change to EyeMed Starting 2/1/2026

Corneal Collagen Cross-Linking

BT2025178: IHCP updates guidelines to allow optometrists to bill chalazion excision services