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    Insurance and cost

    Out-of-network claims and superbills for scleral lenses

    Many specialty lens practices don't bill insurance directly. You pay the practice, they give you a detailed receipt called a superbill, and you file the claim yourself. Here is how that works, what it can and can't recover, and what to ask before you start.

    By the Scleral Lens Team · Last reviewed October 2, 2026 · 11 published sources cited

    The short answer

    A superbill is an itemized statement from the practice with the codes, diagnoses, dates, and provider details your plan needs to process a claim. If your plan has out-of-network benefits, you submit it and the plan reimburses part of the cost based on its own allowed amount, after any deductible and coinsurance. Call your plan first to find out whether you have out-of-network benefits and how much they pay for the codes on your estimate.

    Key points

    • A superbill is a detailed receipt with the codes your plan needs.
    • Reimbursement depends on your out-of-network benefits, deductible, and the plan's allowed amount.
    • Out-of-network care usually costs you more than in-network care.
    • Ask the plan about specific codes before you pay, and get a claim form.
    • Keep copies of everything you send.

    In network, out of network

    Your plan’s network is the providers it has contracts with.[1] A provider without a contract is out of network, sometimes called non-preferred, and you’ll generally pay more to see them.[2]

    The scleral lens fitter you want to see may not be in your network. Some plans still pay part of the cost of out-of-network care; others may pay little or nothing. Your plan documents say which kind you have.

    What a superbill is

    A superbill is an itemized statement from the practice that has everything an insurer needs to process a claim. A claim is simply a request for payment that you or your provider sends to your plan.[3] When the practice doesn’t send it, you do.

    A superbill usually includes:

    • your name, date of birth, and insurance details
    • the practice’s name, address, tax ID, and the provider’s NPI number
    • the date of each service
    • procedure and lens codes for what was done and supplied
    • diagnosis codes explaining why
    • the charge for each line, and what you paid

    The codes are what let the plan match your care to your benefits. The billing codes guide explains the ones you’re likely to see.

    How out-of-network payment is calculated

    Plans don’t pay a percentage of what the practice charges. They pay based on their own allowed amount, the maximum the plan will pay for a covered service.[4] Then:

    1. Your deductible comes off first: the amount you pay for covered services before the plan starts to pay.[7] Some plans have a separate, higher out-of-network deductible.
    2. You pay out-of-network coinsurance, a percentage of the allowed amount, which usually costs more than in-network coinsurance.[6]
    3. If the practice’s fee is higher than the allowed amount, you’re responsible for the difference. This is called balance billing; in-network providers can’t do it for covered services, but out-of-network providers can.[5]

    Vision plans often work differently, paying a fixed out-of-network allowance. For example, one employer’s 2025 VSP plan chart lists a fixed amount the plan pays toward contacts at non-VSP providers, and tells members using a non-VSP provider to submit an itemized receipt.[10]

    How to submit your claim

    1. Call your plan first. Confirm you have out-of-network benefits and ask about the codes on your estimate (see the questions below).
    2. Get the plan’s claim form. Most plans have a member reimbursement form on their website or member portal.
    3. Ask the practice for a superbill after each visit or at the end of the fitting. Check it has codes, dates, and provider details.
    4. Attach supporting documents if the plan asks for them, such as a letter of medical necessity or a prior authorization number.
    5. Submit and keep copies of the form, superbill, and everything else you send. Note the date.
    6. Read the explanation of benefits when it arrives. It shows the allowed amount, what was applied to your deductible, and what was paid or denied.
    7. Appeal if something’s wrong. A claim processed under the wrong benefit, or denied for missing documents, can often be corrected.

    Medicare has its own rules. Medicare only pays for contact lenses from a supplier that participates in Medicare, whether you or your provider submits the claim.[11]

    What to ask your plan before you pay

    1. Do I have out-of-network benefits for this kind of care? Under my medical plan, vision plan, or both?
    2. What is my out-of-network deductible, and how much have I met this year?
    3. What is my out-of-network coinsurance?
    4. What is the allowed amount for these codes: [read the codes from your estimate]?
    5. Is prior authorization required, even out of network?
    6. Is there a deadline for submitting claims?
    7. Where do I send the claim, and what form do I use?

    What to ask the practice

    1. Will you give me a superbill with procedure and diagnosis codes after each visit?
    2. Can you give me the codes in advance so I can check my benefits?
    3. Will you provide a letter of medical necessity or help with prior authorization if my plan requires it?
    4. Do you offer a written estimate for the whole fitting?

    Common questions

    Why don't some scleral lens practices take insurance?

    Practices make that choice for their own business reasons. Out-of-network doesn't mean you can't use insurance at all: it means you pay the practice and seek reimbursement from your plan yourself.

    How long does reimbursement take?

    It varies by plan. Ask the plan how long processing usually takes and how you'll be paid. Note the date you submit and follow up if you don't hear back.

    My plan paid much less than I expected. Why?

    Out-of-network payments are based on the plan's own allowed amount, not the practice's fee, and your deductible and coinsurance come off first. Check the explanation of benefits to see the allowed amount and how the payment was calculated. If you think it was processed under the wrong benefit or code, call the plan or appeal.

    Can I submit to both my medical and vision plans?

    If both plans might cover part of the care, ask each one how it coordinates with the other and in what order to submit. You'll usually need the first plan's explanation of benefits to file with the second.

    Keep reading

    Medical insurance or vision insurance: which one pays for scleral lenses?

    Often it's split. Your medical plan may cover the exams and the fitting for an eye disease like keratoconus, while the lenses themselves are excluded and left to a vision plan, if you have one. Many vision plans have a separate, richer benefit for medically necessary contact lenses. Severe ocular surface disease is sometimes treated differently. Call both plans and ask the questions below.

    Scleral lens billing codes, explained

    Scleral lens claims usually have two kinds of code: a HCPCS code for the lens itself (V2531 is 'contact lens, scleral, gas permeable, per lens') and a CPT code for the fitting, such as 92071 for ocular surface disease or 92072 for the initial keratoconus fitting. A diagnosis code explains why. The practice picks the codes; your plan decides what it pays for them. Knowing the codes helps you ask your plan precise questions.

    Paying for scleral lenses with an HSA or FSA, and other options

    Usually yes. IRS Publication 502 says you can include contact lenses needed for medical reasons as a medical expense, along with the supplies needed to use them, such as saline. That generally makes them eligible for HSA and FSA funds. Keep itemized receipts, check your account administrator's documentation rules, and be careful with deferred-interest medical credit cards.

    How to appeal a denied scleral lens claim

    Start by finding out exactly why the claim or prior authorization was denied. For most private health plans you can then file an internal appeal within 180 days of the denial notice, with a letter from your fitter and the records that answer the reason given. If the plan still says no, you can usually ask for an independent external review. Medicare and some other plan types have their own processes, so check your denial letter.

    Sources

    1. HealthCare.gov. Glossary: Network. healthcare.gov
    2. HealthCare.gov. Glossary: Non-preferred provider. healthcare.gov
    3. HealthCare.gov. Glossary: Claim. healthcare.gov
    4. HealthCare.gov. Glossary: Allowed amount. healthcare.gov
    5. HealthCare.gov. Glossary: Balance billing. healthcare.gov
    6. HealthCare.gov. Glossary: Out-of-network coinsurance. healthcare.gov
    7. HealthCare.gov. Glossary: Deductible. healthcare.gov
    8. Centers for Medicare & Medicaid Services. No Surprises Act: Overview of Key Consumer Protections. Revised June 2026. cms.gov
    9. Centers for Medicare & Medicaid Services. Sample Notice of Uninsured (or Self-Pay) Individual's Right to Receive a Good Faith Estimate. cms.gov
    10. California Institute of Technology, Human Resources. 2025 VSP Vision Plan chart. hr.caltech.edu
    11. Medicare.gov. Eyeglasses & contact lenses. medicare.gov

    Last updated October 2, 2026. Found an error or a newer study? Let us know and we'll correct the page.