Vision claims are processed based on eligible reimbursement rates for Optometric services listed in the Fee Schedule of the Provider Manual. Many restrictions and limitations need to be carefully interrogated before passing the Vision claim for payment

Covered/Non Covered Services
Limitations are placed on Optometric Services covered by the Medical Assistance Program to recipients age 21 and older. The following services are covered for these recipients:

• One(1) refractive eye care examination
• One(1) pair of eyeglasses (lenses, frames and     dispensing fee)
• One (1) pair of contact lenses

Payment is denied for any procedures or services that are unproved, experimental or research in nature.

Services which are not medically necessary to treat the patient's condition, or are not directly related to the patient's diagnosis, symptoms or medical history are not reimbursable under the Medical Assistance Program.

Payment is denied for:

• a spare pair of eyeglasses
• information provided over the telephone
• canceled office visits or appointments not kept
• lost or stolen frames or lenses

Prior Authorization
Contact lenses require prior authorization and will be covered when such lenses provide better management of a visual or ocular condition than can be achieved with spectacle lenses, as well as for Unilateral Aphakia, Keratoconus, Corneal Transplant, and High Anisometropia. This determination will be done through the prior authorization process. Prior Authorization guidelines are defined in the Provider Reference Manual.

Two procedure codes should be used when billing for contact lenses; fitting/dispensing codes and actual lens code.

Special Requirements
Payment for any prior authorized services can only be made if the services are provided while the person remains eligible for Medical Assistance Program.

Unlisted Procedures
Providers who perform an unlisted procedure code must obtain prior authorization for the service before submitting the claim for payment. Medical justification for the procedure must be included with the request for authorization. Prior Authorization guidelines are defined in the Provider Reference Manual.

Crossover Eyeglass Claims Requiring EOMB
Medicare/Medicaid crossover claims for eyeglasses containing diagnosis code V43.1, 379.31 or 743.35 should have the Medicare EOMB attached when submitted to The Medical Assistance Program for payment. If the EOMB is not attached, the claim will be returned to the provider. This policy is effective for claims with dates of service on or after October 1, 1993. Claims not containing one or more of the above diagnosis codes do not require attachment of the EOMB form.

Modifiers
Modifiers should be used when billing for lenses or contact lenses.

TC modifier — Technical component
RT modifier — Right eye
LT modifier — Left eye
26 modifier — Professional component
50 modifier — Bilateral procedure
51 modifier — Multiple procedures
52 modifier — Reduced services (use if billing for one eye only)

Vee will be happy to answer your questions and discuss over a call. Please contact us on 1-877-794-9514 or email at clientservices@veetechnologies.com