Non-Covered Vision Services

Covered benefits by EMI ophthalmologists vary according to the member’s health plan. Refer to the applicable health plan section of the Procedure Manual in the Index under "Non-Covered Services".

In the event that a member requests that your office perform a non-covered vision service, EMI has provided you with the following Vision Fee Information form.

This form explains to the member that the services you are providing are not covered under their benefit package and they are responsible in full for the cost of any non- covered services provided by you.

"The member must be adequately informed prior to receiving non-covered vision services that they will be responsible for the payment of such services."

In addition to written consent by the member, EMI must be notified in advance and give written approval to charge the member for these services.

This form must be signed each time a non-covered vision service is provided.

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