016.06.06 Ark. Code R. 039

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.06-039 - Visual Care Transmittal Update #78

Section II Visual Care

215.000 Evealasses Covered bv Medicaid

Brand	Frame	Gender	Size	Colors
Europa	M-005	Unisex	44&46	Antique Burgundy, and Gun/Matte Black
Kip	Women's	48	Black and Crystal
NF-1	Women's	44&46	Red, and Antique Dark Green
NF-3	Unisex	44&46	Matte,Black and Mette Silver
NF-5	Children's	39-41-43	Brown, Blue, Gunmetal and Gold
Shannon	Women's	46	Violet, Grey, Gold and Blue
Carmen	Unisex	44-46-48	Matte Brown, Matte Gray, Ant. Gold tort. & Vio.
L-Cable	Children's	36-38-40	Brown, Gold and Black
NF-2	Unisex	45&47	Matte,Black and Mette Blue
NF-4	Children's	38-40-42	Brown, Blue and Light Purple
NF-9	Unisex	46&48	Gray Matte and Brown Metallic
NF-11	Men's	52&54	Brown, Black, and Gunmetal
Ken mark	G531	Unisex	45-47	Brown, Black and Matte Gold
Andrea	Women's	49	Rose, Brown and Wne
Shannon	Women's	46-48	Sand, Black and Lavender
Sharon	Women's	49	Black Crystal and Brown
Blaire	Women's	50-52	Golden Rose, Nutmeg and Dove
Jay	Men's	48-50	Brown, Black and Gray
Sam	Men's	49-51	Brown, Gunmetal and Black
Jamie	Women's	44-46	Black/Yellow, Brown and Eine
Henry	Men's	52-54-56-58	Gold, Gold/Demi Amber & Gunmetal/Tortoise
Chet	Men's	54-56	Brown and Gunmetal
Jed	Men's	51-53	Brown, Black and Gray
Steve	Men's	52-54-56	Gray Fade, Demi Amber, Brown Fade & Black
Gwen	Women's	51-53	Beige, Blush and Mist
Louise	Women's	50-52	Brown, Sky and Violet
United	Destiny	Unisex	47	Coffee, C2 Matte Black and C3 Matte Silver
Steve	Men's	49-51	C1 Brown, and C2 Dark Gray

Stella	Women's	51	C1 Light Brown C2 Lilac and C3 Matte Silver
Candy	Unisex	45	C1 Shiny Brown and C2 Matte Black
Modern	Sporty	Kids	44-46	Black/Crystal, Blue and Brown
Gift	Women's	47-49	Black/Crystal, Brown/Crystal & Purple/Brown
Dazzle	Women's	49-51-53	Brown, Gold And Rose
Judi	Women's	50-53	Black/Crystal, Tortoise and Wne/Gray
Dynamite	Girl's	42-45-47	Antique Brown and Black Silver
Zimco	Attitudes#3	Women's	50	Brown/Crystal and Black
Retro#1	Women's	48	Gold, Gunmetal Blue and Matte Brown
Hart	Hart-9756	Women's	48	Brown, Gold and Gunmetal Silver
Hart-8103	Men's	50	Gunmetal, Brown and Black
Hart-8112	Unisex	48	Matte Black, Mattee Burgundy & Matte Coffee
Hart-5634	Women's	47	Black Crystal and Brown Smoke
Hart-5670	Women's	48	Burgundy and Tortoise
Hart-7771	Men's	54	Bordfeaux and Coffee
Hart-5695	Girl's	47	Tortoise, Rose and Black
Hart-5221	Unisex	46	Blue, Brown and Lilac
Hart-9751	Women's	48-50	Brown, Silver and Lilac
Hart 9509	Boy's	38-41-44	Gold Brown,Satin Blue and Shiny Brown
LBI	Woman Day	Woman's	55	Gold, Rose and Gray
LBI-915	Woman's	53	Gold/Silver, Silver Gold and Brown/Gold

243.400 Special Billing Procedures

Prosthetic providers that bill procedure codes V2623 or V2624 electronically must use a type of service (TOS) H with an NU modifier. Prosthetic providers billing either of the above procedure codes on paper must also use a TOS H with an NU modifier.

016.06.06 Ark. Code R. 039

7/6/2006