Vision Services

Medical Coverage Guidelines

Medicaid Vision Manual 

Please note that coverage guidelines and procedures are subject to change. Refer to the monthly Provider Update for recent changes.

• Vision Coverage Guidelines
  • Provider Participation Guidelines
  • Recertification
  • Reimbursement Guidelines
  • Medicare/Medicaid Crossover
  • Patient Liability
  • Covered/Non Covered Services
  • Replacement items
  • EPSDT 
  • Contact Lenses
  • Trifocals
  • Oversized Lenses/Deluxe Frames
  • Polycarbonate Lenses
  • Tints
  • Initial refraction exams 
  • Special Requirements
  • Unlisted Procedures 
  • Claims Billing Guidelines 
  • Crossover Eyeglass Claims Requiring EOMB
  • Modifiers
• Optometric Procedure Codes (see pages 9-31 in the manual here)
  • Surgical Procedures
  • Evaluation and Management Codes (92002-92284)
  • Evaluation and Management Codes (92285-99215)
  • Frames  
  • Single Vision
  • Bifocals
  • Trifocals
  • Prosthetic Eye
  • Other Lens
  • Tints
  • Miscellaneous Codes

Claim Preparation Instructions

CMS 1500 Form Filing Instructions 

Vision Services - CMS 1500 Claim Form 

Error Status Codes

ESC Code List (English) 

Explanation of Benefits (EOB) Codes

EOB Codes and Messages List (English) 

EOB Codes and Messages List (Spanish)

Appendix - Third Party Liability Carrier and Coverage Codes

Third Party Liability Carrier and Coverage Codes

For specific questions you may contact the Customer Service Help Desk at (401) 784-8100 for In-state and long distance callers, or 1-800-964-6211 for In-state toll callers and border communities.