Archived SECTION 13 - BENEFITS AND LIMITATIONS. Section 13 - Benefits and Limitations

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1 SECTION 13 - BENEFITS AND LIMITATIONS 13.1 CONDITIONS OF PARTICIPATION A PROVIDER PARTICIPATION A(1) Optician or Ocularist (Provider Type 32) A(2) Optometric Clinic (Provider Type 53) A(3) Optometrist (Provider Type 31) A(4) Optical Providers Employed by a Medical Clinic A(5) Certified Optometrists (Provider Type 31, Specialty 82) B NOTIFICATION OF PROVIDER C RETENTION OF RECORDS D ADEQUATE DOCUMENTATION D(1) Special Documentation Requirements NONDISCRIMINATION PATIENT ELIGIBILITY A HEALTHY CHILDREN AND YOUTH (EPSDT/HCY) PROGRAM A(1) EPSDT/HCY Prior Authorization Requests B GENERAL RELIEF PATIENTS B(1) Services to General Relief Patients Under 21 Years of Age B(2) Services not Covered for General Relief Patients 21 Years and Over C QUALIFIED MEDICARE BENEFICIARIES (QMB) PROGRAM C(1) How the QMB Program Affects Providers D UNINSURED PARENTS PATIENT NONLIABILITY EMERGENCY SERVICES OUT-OF-STATE, NONEMERGENCY SERVICES A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS PRIOR AUTHORIZATION CERTIFICATE OF MEDICAL NECESSITY A WHEN A CERTIFICATE OF MEDICAL NECESSITY IS REQUIRED

2 13.9 PATIENT COST SHARING AND COPAY A PROVIDER RESPONSIBILITY TO COLLECT COST SHARING OR COPAY AMOUNTS B PATIENT RESPONSIBILITY TO PAY COST SHARING AMOUNTS C COST SHARING AMOUNTS D EXEMPTIONS TO THE COST SHARING AMOUNT E PATIENT RESPONSIBILITY TO PAY COPAY AMOUNTS E(1) Patients Who are Required to Pay A Copay (text del. 5/08) E(2) Services Requiring a Copay E(3) Exemptions to the Copay Amount COVERED SERVICES A EYE EXAMINATIONS A(1) Eye Refraction B SERIAL TONOMETRY C EYEGLASSES C(1) Frames C(2) Special Frames C(3) Lens(es) C(4) Special Lens(es) D OPTICAL MATERIALS E PROSTHETIC EYES F REPLACEMENT/REPAIR OF LENS(ES) AND FRAMES G OFFICE MEDICAL SUPPLY CODE DISPENSING LENS(ES) AND FRAMES EXCEPTION FOR COVERAGE OF CUSTOM MADE ITEMS DUE TO PATIENT LOSS OF ELIGIBILITY ORTHOPTIC AND/OR PLEOPTIC TRAINING FITTING CONTACT LENS(ES) REIMBURSEMENT OF PHARMACEUTICALS NONCOVERED SERVICES

3 13.17 NONALLOWABLE SERVICES MODIFIERS THIRD PARTY LIABILITY (TPL) MC+ MANAGED CARE PROGRAM REPORTING CHILD ABUSE CASES

4 SECTION 13-BENEFITS AND LIMITATIONS 13.1 CONDITIONS OF PARTICIPATION 13.1.A PROVIDER PARTICIPATION To participate in the Missouri Medicaid Optical Program, the optical provider must satisfy the following requirements: The provider must have a Title XIX Optical Participation Agreement in effect with the Missouri Department of Social Services, Division of Medical Services. The optometrist or physician holds a valid current permanent license to practice in accordance with the licensing provisions of the state in which the provider operates or practices. Temporary licenses are not acceptable. The certified optometrist (TPA) license must show the certification from the State Board of Optometry. (Certified optometrists have a specialty of 82.) An optician, optical dispenser or ocularist must have a current Medicaid participation agreement and provider number. A Missouri optometrist and optician must renew his/her license annually to continue participation as a Medicaid provider. A physician (provider type 20 or 24) with the specialty of ophthalmology (18), who intends to bill for optical supplies or prosthetic eyes, must obtain an optical provider number. The provider may not use the physician provider number in the Optical Program to bill Medicaid. Optical services, such as eyeglasses, lens and frames, are not covered under the Physician s Program. If a provider s license is suspended or terminated by the state licensing agency, the Division of Medical Services Participation Agreement is also suspended or terminated effective the same date. Additional information on provider conditions of participation can be found in Section 2 of this provider manual A(1) Optician or Ocularist (Provider Type 32) An optician or ocularist may only bill for optical materials (eyeglasses) or prosthetic eyes and services. If the optical company or ocularist employs an optometrist, the eye examination must be billed on a separate claim using the optometrist's Medicaid provider number. When the optometrist is an employee of 4

5 an optical company or an ocularist, the "pay to" name and address for the optometrist Medicaid provider number should show the name and address of the optical company or ocularist A(2) Optometric Clinic (Provider Type 53) An Optometric clinic must have an optometric clinic Medicaid provider number and a current Title XIX Clinic Participation Agreement in effect, in addition to the optometric clinic Medicaid provider number. Each performing optometrist must also have an active Optical Provider Participation Agreement. Reimbursement can be made to the clinic for all services provided at the clinic, including eye examinations, eyeglasses, prosthetic eyes and special ophthalmologic services A(3) Optometrist (Provider Type 31) An optometrist must have a current Optical Participation Agreement in effect. Reimbursement for optometric services includes: eye examination, eye glasses and prosthetic eyes. Special ophthalmologic services must be submitted by a certified optometrist. Reference Section 13.1.A(5) for more information on certified optometrist A(4) Optical Providers Employed by a Medical Clinic The medical clinic provider number beginning with "50" is designated for the physician (M.D. and D.O.) services. Optometrists/Opticians/Ocularists who are employed by a medical clinic other than a optometric clinic may not bill as performing provider for optical services under the medical clinic provider number (provider type 50). Optical providers must bill for the services they furnish using an individual provider number (provider type 31 or 32) or under an optometric clinic number, provider type 53. Additional information on provider conditions of participation and provider enrollment can be found in Section A(5) Certified Optometrists (Provider Type 31, Specialty 82) An optometrist certified in the administration of applied diagnostic or therapeutic pharmaceutical agents in the practice of optometry, may also remove superficial foreign bodies from the eye and adnexa. Provider specialty "82" is added to the optometrist s provider record to allow reimbursement of services limited to a 5

6 certified optometrist. Refer to Section 19 for procedure codes that can be used by certified optometrists to bill for services provided to Medicaid patients in conjunction with the removal of superficial foreign bodies from the eye and adnexa and the administration of topically applied or therapeutic pharmaceuticals. An optometrist may not perform surgery upon the eye including the use of laser for treatment of any disease or condition or for the correction of refractive error. Procedures that require the penetration or repair of anatomic tissue by any energy, material, device or instrument are not covered by Medicaid as these services are not within the scope of optometric practice B NOTIFICATION OF PROVIDER The Provider Enrollment Unit must be notified in writing of any changes in provider records. The notification must include the provider number and the requested changes. Example of changes are: Address (including "pay to" address) or telephone number change; change from a Social Security number to Tax Payer I.D. number, name change, etc. Reference Section 2 for additional information C RETENTION OF RECORDS Medicaid providers must retain for 5 years, from the date of service, fiscal and medical records that coincide with and fully document services billed to the Medicaid Agency, and must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal and retain adequate documentation for services billed to the Medicaid Program may result in recovery of the payments for those services not adequately documented and may result in sanctions to the provider's participation in the Medicaid Program. This policy continues to apply in the event of the provider's discontinuance as an actively participating Medicaid provider through change of ownership or any other circumstance D ADEQUATE DOCUMENTATION All services provided must be adequately documented in the medical record. The Code of State Regulations, 13 CSR , Section (1)(A) defines "adequate documentation" and "adequate medical records" as follows: Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. 6

7 Adequate medical records are records which are of the type and in a form from which symptoms, conditions, diagnoses, treatments, prognosis and the identity of the patient to which these things relate can be readily discerned and verified with reasonable certainty. All documentation must be made available at the same site at which the service was rendered D(1) Special Documentation Requirements Reimbursement for eyeglasses, lens(es) or frames must contain the following documentation in the patient's medical record. A copy of the prescription and the name of the prescribing physician (M.D. or D.O.) or optometrist (O.D.). The laboratory invoice, which lists the cost for the optical materials, lens(es), frames, and charges for grinding, edging or assembling of glasses NONDISCRIMINATION Providers must comply with the 1964 Civil Rights Act, as amended; Section 504 of the Rehabilitation Act of 1973; the Age Discrimination Act of 1975; the Omnibus Reconciliation Act of 1981 and the Americans with Disabilities Act of 1990 and all other applicable Federal and State Laws that prohibit discrimination in the delivery of services on the basis of race, color, national origin, age, sex, handicap/disability or religious beliefs. Further, all parties agree to comply with Title VII of the Civil Rights Act of 1964 which prohibits discrimination in employment on the basis of race, color, national origin, age, sex, handicap/disability, and religious beliefs PATIENT ELIGIBILITY The patient of Optical Program services must be eligible on the day the service is provided or the eyeglasses are dispensed. A prior authorized service is only covered when the patient is eligible on the date of service. The only exception to the eligibility requirement is explained in Section It is the responsibility of the provider to verify the patient's eligibility on the day that the optical material or service is provided or the eyeglasses are dispensed to ascertain that the bearer is the person to whom the ID card was issued and that the patient is eligible as of that date. The patient's eligibility status can be obtained through the following methods: Through the Interactive Voice Response (IVR) system. Using the IVR provides quick, accurate eligibility information that should greatly reduce claim rejection. Providers may 7

8 access current information such as eligibility dates, medical eligibility code restrictions, available third party resources, lock-in restrictions and more. Using the point of service (POS) eligibility verification. The POS eligibility verification system is available to all Missouri Medicaid providers. Accessing information through the POS eligibility verification system requires a POS terminal and a single line phone jack. Reference Section 1 and Section 3 for more information regarding the POS eligibility verification system. Using the Internet. Reference Section 3.3.D for more information Viewing the Recipient Eligibility Letter. Missouri Medicaid patients who are approvals or need a replacement card are given an eligibility letter from the Family Support Division until an ID card can be issued. These letters are valid proof of eligibility. Dates of eligibility and applicable restrictions are contained in these letters. Additional information about patient eligibility can be found in Section A HEALTHY CHILDREN AND YOUTH (EPSDT/HCY) PROGRAM A medically necessary item or service that is normally non-covered that is identified as a result of a physician, optometrist or other health care professional visit or exam screen may be covered for persons under 21 years of age, on a prior authorization basis. It is important to note that every Medicaid eligible child have a completed EPSDT/HCY screen. If the child has not had a full screen, the provider should refer the child for a full screen to be done at a later date. Reference Section 9 for information about EPSDT/HCY screening services A(1) EPSDT/HCY Prior Authorization Requests The following guidelines must be used to request an EPSDT/HCY prior authorization: Prior Authorization Requests for coverage of non-covered items/services that do not have specific procedure codes, such as medical supplies, replacement eyeglasses, replacement lens(es), special optical testing, etc., must be sent to Infocrossing Healthcare Services, P.O. Box 5700, Jefferson City, MO The Prior Authorization Request form should be clearly marked as an EPSDT/HCY request. The procedure code to use is V2799, if there is not a specific code. Reference Section 19 for a list of procedure codes and their billing requirements. 8

9 The following documentation must be included on, or submitted with the Prior Authorization Request form for procedure code V2799: The nature of the item or service to be provided, the duration of time the item is needed and the projected outcome; A manufacturer's invoice of cost showing the provider's cost if the request is for a special type of optical services. After the consultant reviews the Prior Authorization Request, a decision is made regarding medical necessity and approval of each service. After review by the consultant, a Missouri Medicaid Authorization Determination is sent to the provider. Reference Section 8.7 for more information regarding the Missouri Medicaid Authorization Determination. Prior authorization approves the medical necessity of the item or service requested. Prior authorization does not establish Medicaid eligibility. The patient must be Medicaid eligible on the date of service B GENERAL RELIEF PATIENTS General Relief (GR) is a state-only funded program designed to assist those in the Missouri population who do not meet eligibility requirements for any federal assistance program. The state-only General Relief Medical Assistance Program is more restrictive than the federally matched programs under Title XIX (Medicaid). GR patients have restricted service benefits and are identified by their category of assistance as restricted beneficiaries. A GR patient may present an Approval Notice letter or replacement I.D. letter from the county Family Support Division office as proof of eligibility when an ID card is not available or when an ID card has been lost or stolen. Each letter contains a box in the upper right-hand corner that has been checked to identify the bearer as a GR case. GR patients are identified on the interactive voice response (IVR) system, (573) , on a point of service (POS) terminal by ME code "09"or through the Internet at B(1) Services to General Relief Patients Under 21 Years of Age Similar to other patient categories of eligibility, medically necessary services to GR patients under 21 years of age covered under the Healthy Children and Youth (EPSDT/HCY) Program. Reference Section 9 and Section 13.3.A for additional information 13.3.B(2) Services not Covered for General Relief Patients 21 Years and Over 9

10 The Division of Medical Services provides reimbursement for medical and surgical services when provided by an optometrist for General Relief (GR) patients. GR patients age 21 and over have restricted coverage which is limited to optical care for trauma and disease only. General optical care for refractive errors including eyeglasses, as provided by an optometrist or optical company, are not covered for GR patients age 21 and over C QUALIFIED MEDICARE BENEFICIARIES (QMB) PROGRAM Section 301 of the Medicare Catastrophic Coverage Act of 1988 makes individuals who are Qualified Medicare Beneficiaries (QMB) a mandatory coverage group under Medicaid for the purpose of paying Medicare deductible and coinsurance amounts on their behalf. Refer to Section 1 for detailed information on QMB patients C(1) How the QMB Program Affects Providers It is important for providers to understand the difference between the services Medicaid reimburses for those individuals with QMB-only and for those with QMB and Medicaid eligibility. For a QMB-only patient, Medicaid only reimburses providers for Medicare deductible and coinsurance amounts for services covered by Medicare. The medical eligibility code of the QMB-only patient is "55." A dual eligible QMB and Medicaid patient may receive all services (within limitations) covered by Missouri Medicaid and provided by Medicaid enrolled providers. Medicaid covers all Medicare deductible and coinsurance amounts for services furnished by providers who may or may not participate in Medicaid. Reference Section 2.1.A for further information D UNINSURED PARENTS 13.4 PATIENT NONLIABILITY Medicaid covered services rendered to an eligible patient are not billable to the patient if Medicaid would have paid had the provider followed the proper policies and procedures for obtaining payment through the Medicaid Program as set forth in 13 CSR EMERGENCY SERVICES 10

11 Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing the patient's health in serious jeopardy; or 2. Serious impairment to bodily functions; or 3. Serious dysfunction of any bodily organ or part OUT-OF-STATE, NONEMERGENCY SERVICES All nonemergency, Medicaid covered services that are to be performed or furnished out-of-state for eligible Missouri Medicaid patients, and for which Missouri Medicaid is to be billed, must be prior authorized before the services are provided. Services that are not covered by the Missouri Medicaid Program are not approved. Out-of-state is defined as not within the physical boundaries of the State of Missouri nor within the boundaries of any state that physically borders on the Missouri boundaries. Border-state providers of services (those providers located in Arkansas, Illinois, Iowa, Kansas, Kentucky, Nebraska, Oklahoma and Tennessee) are considered as being on the same Medicaid participation basis as providers of services located within the State of Missouri. A Prior Authorization Request form is not required for out-of-state nonemergency services. To obtain prior authorization for out-of-state, nonemergency services, a written request must be submitted by a physician to: The request may be faxed to (573) The written request must include: 1. A brief past medical history. 2. Services attempted in Missouri. Division of Medical Services Recipient Services Unit P.O. Box 6500 Jefferson City, MO Where the services are being requested and who will provide them. 4. Why services can t be done in Missouri. 11

12 NOTE: The out-of-state medical provider must agree to complete an enrollment application and accept Missouri Medicaid reimbursement. Prior authorization for out-of-state services expires 180 days from the date the specific service was approved by the state A EXCEPTIONS TO OUT-OF-STATE PRIOR AUTHORIZATION (PA) REQUESTS The following are exempt from the out-of-state prior authorization requirement: 1. All Medicare/Medicaid crossover claims. 2. All Foster Care children living outside the State of Missouri. However, nonemergency services that routinely require prior authorization continue to require prior authorization by out-of-state providers even though the service was provided to a Foster Care child. 3. Emergency ambulance services. 4. Independent laboratory services PRIOR AUTHORIZATION Under the Missouri Medicaid Program, certain covered services and equipment require prior approval if the provider is to be reimbursed for them. Prior authorization is used to promote the most effective and appropriate use of available services and to determine the medical necessity of the service. Reference Section 19 for procedure codes that require prior authorization. The provider must submit a Prior Authorization Request form to DMS before the service is provided in order for Medicaid payment to be made. Prior authorization for dispensing optical materials or providing services expires 180 days from the date of approval by the DMS Optical Consultant. If the service date on the claim indicates that the service was provided more than 180 days after the prior authorization approval, the claim is denied CERTIFICATE OF MEDICAL NECESSITY Certain services, procedures or circumstances require that a Certificate of Medical Necessity form be attached to a paper claim when it is submitted for payment. If the Certificate of Medical Necessity form supports the need for service and/or why another policy cannot be followed, the service may be payable. Section 7 provides a full explanation of the purpose of this form, including instructions for completion and a sample form. 12

13 13.8.A WHEN A CERTIFICATE OF MEDICAL NECESSITY IS REQUIRED Each circumstance that requires a Certificate of Medical Necessity form is discussed separately. Reference Section 19 for procedure codes that require a Certificate of Medical Necessity PATIENT COST SHARING AND COPAY Patients eligible to receive certain Missouri Medicaid services are required to pay a small portion of the cost of the services. This amount is referred to as cost sharing or copay. The cost sharing or copay amount is paid by the patient at the time services are rendered. Services of the Optical Program described in this manual are subject to a cost sharing or copay amount. The provider must accept in full the amounts paid by the state agency plus any cost sharing or copay amount required of the patient A PROVIDER RESPONSIBILITY TO COLLECT COST SHARING OR COPAY AMOUNTS Providers of service must charge and collect the cost sharing or copay amount. Providers of service may not deny or reduce services to persons otherwise eligible for benefits solely on the basis of the recipient's inability to pay the fee when charged. A patient's inability to pay a required amount, as due and charged when a service is delivered, shall in no way extinguish the recipient's liability to pay the amount due. As a basis for determining whether an individual is able to pay the charge, the provider is permitted to accept, in the absence of evidence to the contrary, the patient's statement of inability to pay at the time the charge is imposed. The provider of service must keep a record of cost sharing or copay amounts collected and of the cost sharing or copay amount due but uncollected because the patients did not make payment when the service was rendered. The cost sharing or copay amount is not to be shown as an amount received on the claim form submitted for payment. When determining the reimbursement amount, the cost sharing or copay amount is deducted from the Medicaid maximum allowable amount, as applicable, before reimbursement is made B PATIENT RESPONSIBILITY TO PAY COST SHARING AMOUNTS Unless otherwise exempted (Refer to Section 13.9.D), it is the responsibility of the patient to pay the required cost sharing amount due. Whether or not the patient has the ability to pay 13

14 the required cost sharing amount at the time the service is furnished, the amount is a legal debt and is due and payable to the provider of service C COST SHARING AMOUNTS Unless an exemption applies, the following cost sharing amounts are applied to all Optical Program services: MEDICAID MAXIMUM ALLOWABLE COST SHARING AMOUNT or less to $ to $ or more D EXEMPTIONS TO THE COST SHARING AMOUNT The following patients or conditions are exemptions to the patient's responsibility to the cost sharing amount as they apply to the Optical Program: Patients ages 17 and under are exempt from cost sharing amounts. Patients age 18 and over must pay the cost sharing amount unless the individual is a foster care child or meets another exemption: Early Periodic Screening, Diagnosis, and Treatment screening and related services (up to 21 years of age); Foster Care Children up to 21 years of age; (ME codes 07 and 08) Hospice patients; Patients who have both Medicare and MO HealthNet entitlement if Medicare covers the service; Institutionalized patients who are residing in a skilled nursing facility, a psychiatric hospital, a residential care facility, or an adult boarding home; MO HealthNet for Kids managed care health plan enrollees for services provided by the MO HealthNet for Kids managed care health plan, except that MO HealthNet for Kids managed care health plan enrollees must pay the shared pharmacy dispensing fee. MO HealthNet for Kids managed care health plan enrollees whose services are outside of the plan benefit must pay the cost sharing amount when applicable; 14

15 The exemption to the cost sharing amount is identified by MHD when processing the claim E PATIENT RESPONSIBILITY TO PAY COPAY AMOUNTS It is the responsibility of the patient to pay the required copay amount due. Whether or not the patient has the ability to pay the required copay amount at the time the service is furnished, the amount is a legal debt and is due and payable to the provider of service. The copay only applies to identified services and patients with certain ME codes E(1) Patients Who are Required to Pay A Copay (text del. 5/08) 13.9.E(2) Services Requiring a Copay The following services require a copay: S0620 S S0621 S For a complete description of these procedure codes, refer to a current edition of the Current Procedural Terminology (CPT) and the Health Care Common Procedure Coding System (HCPCS) books E(3) Exemptions to the Copay Amount Copay is exempt for an office visit/well child check with a diagnosis code of V20.2, V68.0, V70.0 or V70.3. No copay on treatment services. The provider should collect only one copay amount when they furnish more than one service requiring a copay at a single office visit on the date of service. MHD does not deduct the copay on the professional provider's services for procedures requiring a copay when the place of service (POS) is 21 (inpatient), 22 (outpatient), 23 (emergency room), 24 (ambulatory surgical center), 51 (inpatient psychiatric facility), 61 (comprehensive inpatient rehab facility), and 62 (comprehensive outpatient rehab facility). MHD only requires a patient to pay a copay amount to the inpatient hospital, outpatient facility when seen in an outpatient or emergency room (if the 15

16 hospital bills a facility charge code), or when the ambulatory surgical center (ASC) charges the copay. The professional provider should also not charge a copay when services are provided in these settings COVERED SERVICES This section provides information regarding the coverage and limitations of optical services. Reference Section for further information for MC+ managed health care enrollees. Reference Section 9 for further information on EPSDT/HCY services A EYE EXAMINATIONS Payment for eye examinations can only be made to an optometrist or an optometric clinic. One comprehensive, or one limited eye examination is allowed per year (during a 12-month period of time) under the Medicaid Program for refractive error. Claims with optical exam procedure codes S0620 (Routine ophthalmological exam including refraction; new patient;complete exam), S (Routine ophthalmological exam including refraction; new patient; limited exam), S0621 (Routine ophthalmological exam including refraction; established patient; complete exam), S (Routine ophthalmological exam including refraction; established patient; limited exam), must contain one or more of the following diagnosis codes: (After-cataract, unspecified) (Soemmering s ring) (Other after-cataract, not obscuring vision) (After-cataract, obscuring vision) (Hypermetropia) (Myopia) (Astigmatism, unspecified) (Regular astigmatism) (Irregular astigmatism) (Anisometropia) (Aniseikonia) 16

17 367.4 (Presbyopia) (Paresis of accommodation) (Total or complete internal ophthalmoplegia) (Spasm of accommodation) (Transient refractive change) (Other disorders of refraction and accommodation, other) (Unspecified disorder of refraction and accommodation) V72.0 (Examination of eyes and vision) Do not use the above diagnosis codes on claims when treating patients for disease or trauma to the eye. Payment for a comprehensive eye examination (S0620 new patient or S0621 established patient) is made only if six or more of the following procedures have been performed: Refraction far point and near point Case history Visual acuity testing External eye examination Pupillary reflexes Ophthalmoscopy Ocular motility testing Binocular coordination Vision fields Biomicroscopy (slit lamp) Tonometry Color vision Depth perception 17

18 If fewer than six of these procedures are performed, a limited examination ( S new patient or S established patient) must be billed. Only one optical evaluation or office visit can be billed on a single date of service. Additional eye examinations are allowed, within the 12-month period of time following the placement of lens(es), if medically necessary (e.g., cataract examination, glaucoma examination). Reference Section 19, Procedure Codes, for additional optical exam procedure codes. Additional eye examinations with a refraction may be allowed, within the 12-month period of time following the placement of lens(es), if medically necessary for a prescription change of 0.50 diopters or greater. A Certificate of Medical Necessity is required showing the previous prescription and the new prescription. The same Certificate of Medical Necessity can be used for new lens(es) and/or frames that are the result of this eye examination. Reimbursement of an additional eye examination with refraction, during the 12-month period following the placement of lens(es), which determined there was not a 0.50 diopter change, may be made if it is not possible to obtain the prescription of the previous eye examination by another provider. A Certificate of Medical Necessity form must be attached to the paper claim form for the eye examination explaining why the exam was performed within the 12- month rolling period. If an adult loses or breaks glasses, frames or lens(es), another eye examination with or without a refraction for the purpose of replacing the frames and/or lens(es) is not covered during the 12-month period following the examination for these glasses, frames or lens(es). Reference Section F for information on replacement/repair of eyeglasses A(1) Eye Refraction An eye refraction is included in the reimbursement for a comprehensive or limited eye examination. Because the eye refraction is not covered by Medicare but is covered by Medicaid, providers may bill Medicaid for an eye refraction (procedure code 92015) when the patient has Medicare and Medicaid coverage. Eye examinations given to Medicare/Medicaid patients that are covered by Medicare must be billed to Medicare first. Reference Section 16, Medicare/Medicaid Crossover Claims, for more information B SERIAL TONOMETRY Serial tonometry with optometric diagnostic evaluation (separate procedure), one or more sessions on the same day, procedure code 92100, is covered when performed by an 18

19 optometrist. Routine tonometry is included in the reimbursement for a comprehensive examination and cannot be billed separately on the same date as a comprehensive eye exam C EYEGLASSES Eyeglasses are covered under the frames and lens(es) limitations as they are separately billable. Refer to Section C(1) and Section C(2) and Section C(3). Eyeglasses can not be mailed to a patient, and must be delivered by the optician or a qualified employee of the optician to assure the frame fits properly and the lens(es) are correct for the patient C(1) Frames Frames are covered when the prescription for lenses meets the coverage guidelines as stated in Section C(3) and may only be replaced every 24 months. Temples may never be billed in addition to new frames. When billing for frames only, after the 24-month limitation period, the provider must indicate on the paper claim, in Field #19, the prescription of the lens that will be placed into the frame. All electronic and Internet claims for frames only must contain the prescription information. Refer to Section 15.1 and Section 15.2 for information on electronic and Internet claims. The prescription must show a correction of 0.75 diopters, in at least one eye, in order for the frames to be covered. If a patient requests a more expensive pair of frames than provided under the Medicaid Program, the patient may purchase their own frames. The patient must pay the full amount of the frames. The provider cannot bill Medicaid for frames that the program covers and accept payment from the patient for the difference of the selected non-covered frames. Accepting a portion of payment for services from a patient is in violation of State Regulations 13 CSR (2)(A) 9 and 13 CSR (2)(A) C(2) Special Frames Special frames (procedure code V202022) are covered under the Medicaid Program if medically necessary. Special frames are covered: if the patient requires special lens(es) over 4.00 diopters for one eye, or over 4.00 diopters for each eye and are extra thick or heavy; if the structure of the patient's face requires special frames (a very large face, wide-set eyes); or 19

20 if the patient needs glasses with pads because of nose surgery C(3) Lens(es) Claims for lens(es) are covered when the prescription is at least 0.75 diopters for one eye or 0.75 diopters for each eye. The 0.75 diopters must be in either the sphere, the cylinder, or add power. Lens(es) may be covered for a prescription of less than 0.75 diopters if medically necessary. A Certificate of Medical Necessity form must be completed by the prescribing physician or optometrist and attached to the paper claim form. Lens(es) less than 0.75 diopters are approved for the following reasons: Child under age 18 requires glasses for school performance; Visual acuity 20/40 or less; Protective eye wear for persons with sight in only one eye; Plano lens when there is a refractive error in only one eye. One pair of lenses and frames is allowed every 2 years (during any 24-month period of time) for Medicaid patients. Refer to Section F for information regarding replacement. Plastic lens(es) may be dispensed under the Medicaid Program. Reimbursement is the same rate as comparable glass lens(es). Single vision, bifocal and tri-focal lenses are covered by Medicaid. All claims for frames or lens(s) must contain the prescription. When applicable, the prescription for lens(es) must be written in minus cylinder when submitting a claim and/or the Certificate of Medical Necessity form C(4) Special Lens(es) Special lens(es) are covered under the Medicaid Program if they are medically justified. A special lens is described as a sphere power of plus or minus 4.00 or greater and/ or cylinder minus 3.25 or greater and/or an add power of 3.50 or greater. Other items which may be billed as a special lens include, but are not limited to, prism, slab-off prism and progressive lens (only if the patient s medical record shows the new progressive lens[es] are replacing progressive lens[es]). Photochromatic lens(es) are covered. Tinted lens(es) (Rose I and Rose II) are covered. 20

21 Polycarbonate lens(es) are only covered when the patient has a medical condition which warrants the need for these special lens(es). Examples of medical reasons are: a patient might have a seizure disorder which would cause them to fall down and break their glasses, a patient has only one eye and needs the lens to protect their good eye. U-V lenses and anti-reflective lenses are only covered after cataract surgery D OPTICAL MATERIALS Optical materials dispensed through the Medicaid Program must meet the following standards: Frames must be sturdy and of good quality. Lens(es) must be of safety type glass or plastic complying with Federal Regulations and substantially meet ANSI standards. Any warranties extended by optical companies for optical materials to private-pay patients must also apply to those same materials dispensed to Medicaid patients E PROSTHETIC EYES Medicaid allows one prosthetic eye per eye (one left and one right) within a five-year period. If the prosthetic eye is lost, destroyed, cracked or deteriorated, payment is allowed for replacement if a Certificate of Medical Necessity form, which explains the reason for the replacement, is attached to the claim. Refer to the Section 19 for eye prosthesis services. Checking the prosthesis (including cleaning and polishing) is a covered service F REPLACEMENT/REPAIR OF LENS(ES) AND FRAMES Medicaid covers one pair of lens(es) and frames per patient every 2 years (during any 24- month period). Replacement of frames is not covered during the 24 months period following the date of service of the Medicaid purchased frames. Replacement of a lens(es) is not covered within the 24 months period following the date of service of the Medicaid purchased lens(es) except if medically necessary because of a prescription change of at least 0.50 diopters for one eye or 0.50 diopters for each eye. If there is a 0.50 diopter change in only one eye, Medicaid only replaces the lens for the eye with the 0.50 diopter change, not both eyes. 21

22 In order to bill for replacement of lens(es) due to a prescription change, a completed Certificate of Medical Necessity must be sent with a paper claim form. The Certificate of Medical Necessity form must contain both the old and new prescriptions. Refer to Sections 14.3 for more information. Replacement or repair of optical materials when the damage was due to patient abuse is not covered. The patient is responsible for any such charges. Replacement of lost or broken glasses, frames or lens(es) is a covered service for patient's under 21 years of age. Procedure code V2799 must be prior authorized. The lens(es) prescription and the procedure code(s) of the items being requested must be written on the Prior Authorization Request in the Description of Service/Item Field. Reference Section 8 for general information about requesting prior authorization. Reference Section 13.3.A, Healthy Children And Youth (EPSDT/HCY) Program G OFFICE MEDICAL SUPPLY CODE Optometrists and opticians may bill for supplies and materials in addition to an office visit or minor surgical procedure (reference Section 19.12) if these supplies are over and above those usually included with the office visit. Appropriate supplies may be billed by the provider by using procedure code The manufacturer's invoice of cost for the supply must be attached to the paper claim. Supplies such as gowns, drapes, gloves, eye patches, eye bandages, tape, gauze, sterile swabs, etc., are included in the office visit and may not be billed separately. Providers may not bill for any reusable supplies DISPENSING LENS(ES) AND FRAMES Lens(es) and frames must be dispensed to the patient before the provider bills Medicaid. Holding the lens(es) and frames until Medicaid payment is received constitutes a payment for a service not provided and is in violation of State Regulation 13 CSR (2)(A) 23. The patient's Medicaid eligibility must be verified on the date the optical materials or services are dispensed to ensure the person is eligible. If the patient is not eligible on the day an office visit or eye examination is performed, the patient is responsible for payment. If the patient is not eligible on the date a custom made item is dispensed, refer to Section for payment guidelines. Eyeglasses can not be mailed to a patient, and must be delivered by the optician or a qualified employee of the optician to assure the frame fits properly and the lens(es) are correct for the patient. 22

23 Providers may not request or accept a deposit from a Medicaid patient and then refund it after payment is received from Medicaid. Accepting a deposit or portion of the fee or charge is in violation of State Regulation 13 CSR (2)(A) EXCEPTION FOR COVERAGE OF CUSTOM MADE ITEMS DUE TO PATIENT LOSS OF ELIGIBILITY The patient must be eligible on the date a service is provided or the prosthetic eye(s), lens(es) or complete eyeglasses are dispensed. This is a requirement even if the service has been prior authorized. It is the responsibility of the provider to verify the patient's eligibility on the date that the frames, lens(es) or complete eyeglasses are ordered or dispensed to ascertain that the patient is eligible on that date. However, Medicaid payment may be made for the prosthetic eye(s), lens(es) or complete eyeglasses when the patient becomes ineligible for the service or dies after the prosthetic eye(s), lens(es) or complete eyeglasses are ordered and before the prosthetic eye(s), lens(es) or complete eyeglasses can be dispensed. The following prerequisites apply to all such payments: There must have been a commitment by the provider to provide the service and to accept the Medicaid payment based upon verified Medicaid eligibility at the initiation of the service; There must have been reason to believe that the patient's Medicaid eligibility would continue; The patient must have been eligible when the service was first initiated and following receipt of an approved Prior Authorization Request, if required, and at the time any subsequent service, preparatory and prior to the actual ordering of the fabrication of the device or item; The custom-made device or item must have been fitted and fabricated to the specific medical needs of the user in such a manner so as to preclude its use for medical purpose by any other individual; and The custom-made device or item must have been delivered or placed if the patient is living. Payments under this exception are made as follows: If the custom item is dispensed to the patient following loss of Medicaid eligibility and all of the prerequisites listed above have been met, the payment is the lesser of the "net billed charge" or the Medicaid maximum allowable amount for the total service, less any applicable cost sharing. 23

24 If the item cannot be dispensed due to death of the patient, the payment is the lesser of the "net billed charge" or the Medicaid maximum allowable amount for the total service, less any applicable cost sharing. The "net billed charge" shall be the provider's usual and customary billed charge(s) as reduced by any salvage value amount. If the provider determines the patient has lost eligibility after the service is first initiated and before the custom-made item is actually ordered or fabricated, the patient must be immediately advised that completion of the work and delivery or placement of the item is not covered by Medicaid. It is then the patient's choice to request completion of the work on a private payment basis. If patient death is the reason for loss of eligibility, the provider can, of course, proceed no further and there is no claim for the non-provided item of service. This policy does not apply to a situation in which: The prosthetic eye, lens(es) or frames cannot be dispensed because the patient refuses to accept the item. If a patient refuses to accept the item, Missouri Medicaid does not reimburse the provider. Procedures for submitting a claim under this exception are as follows: The date of service that is shown on the claim for the item (glasses, prosthetic eye, etc.) must be the last date on which service is provided to the eligible patient (and following receipt of an approved Prior Authorization Request, if required) prior to the ordering or fabrication of the item. The provider is responsible for verifying patient eligibility each time service is provided. Use of a date for which the patient is no longer eligible for Medicaid coverage of the service results in a denial of the claim. The claim is to be submitted to the fiscal agent in the same manner as other claims ORTHOPTIC AND/OR PLEOPTIC TRAINING Optometrists may be reimbursed for orthoptic and/or pleoptic training, with continuing optometric direction and evaluation (visual training/therapy), procedure code 92065, when there is a prognosis for substantial improvement or correction of an ocular or vision condition. These conditions include amblyopia, eccentric (nonfoveal) monocular fixation, suppression, inadequate motor or sensory fusion, and strabismus (squint). Orthoptic and pleoptic training must be prior authorized. The number of training sessions are limited to 1 per day, 2 per week and a maximum of 20 sessions may be requested on the Prior Authorization Request form. If the patient shows significant improvement after the initial 20 sessions, and the optometrist feels that further progress can be made, DMS may grant prior authorization for additional training sessions not to exceed a total of 40 sessions. 24

25 The Prior Authorization Request form must include the patient's age, relevant history, refractive error, corrected visual acuity, condition for which the treatment is requested, details of the type, scope and number of treatments planned, estimated cost, and prognosis for correction of existing condition. An eye examination or office visit may be allowed at the initial visual therapy session if medically necessary. A Certificate of Medical Necessity form stating the reason an eye examination is required must be attached to the claim for the visual therapy-related eye examination. Eye examinations or office visits at subsequent therapy sessions are noncovered FITTING CONTACT LENS(ES) Contact lens(es) and fitting of the contact lens(es) used as a therapeutic bandage for the treatment of disease, including a supply of lenses without corrective power are covered. Use procedure code when billing for this service. Diagnoses for which the lens(es) are reimbursed are Bullous Kerotopathy, Corneal Ulcers, Ocular Pemphigoid and other corneal exposure problems. A Certificate of Medical Necessity form completed and signed by the prescribing physician must be submitted with the paper claim. Contact lens(es) with corrective power for visual improvement is not covered for patients 21 years and older. Contact lenses with refractive errors are covered for children when the diagnosis is Anisometropia of 4.00 diopters or greater in one eye; Keratoconus; and Aphakia. A Certificate of Medical Necessity form completed and signed by the prescribing physician must be submitted along with a manufacturer's invoice of cost for the contact lens(es) REIMBURSEMENT OF PHARMACEUTICALS An optometrist who has become certified to administer pharmaceutical agents may prescribe a pharmaceutical; however, Medicaid reimbursement for pharmaceutical agents are through the Pharmacy Program and cannot be made directly to optometrists through the Optical Program NONCOVERED SERVICES Noncovered services are not billable to Medicaid and are billable to the Medicaid patient as long as the patient is aware they are financially responsible for the service. The following items/services are noncovered: Adjustments for eyeglasses not furnished by the provider to the Medicaid patient; Contact lens(es) other than for medical purposes as stated in Section 13.14; Eyeglass cases; 25

26 Eyeglass frames with hearing aids attached; Frames and lens(es), when there is not a 0.75 diopter prescription in either eye. Reference Section C(3), for more information; Magnifiers; Monocles; Nose pads; Optical materials not meeting standards; Optical materials that are not medically necessary; Optical services or materials provided to a patient who was not eligible on the date the service was provided or the optical materials were delivered to the patient. Refer to Section for custom-made items; Ornamental, jeweled and trimmed frames; Oversized lens(es) other than for medical purposes; Prism therapy; Replacement of optical materials resulting from patient abuse; Sales or use tax on optical materials not reimbursed by Medicaid; (the patient is responsible for and may be billed for such taxes on a non Medicaid covered item); Scratch resistant coating; or Sunglasses NONALLOWABLE SERVICES The following services are not billable to the patient or to the Medicaid agency: Analysis of information data stored in computers; Canceled or no show appointments; Claim filing fees; Collection, handling, conveyance, and/or any other service in connection with the implementation of an order involving devices (e.g., designing, fitting, packaging, handling, delivery or mailing); Courtesy calls/visits during which no identifiable medical service was rendered; Educational supplies, such as books, tapes and pamphlets provided by the optometrist; Eyeglass adjustments on eyeglasses made by the provider; 26