Section II Visual Care 201.000 Arkansas Medicaid Participation Requirements for Visual Care Providers
Visual Care Program providers meeting the following criteria are eligible for participation in the Arkansas Medicaid Program:
A. Provider must be licensed by the State Board of Optometry to practice in his or her state. A current copy of the optometrist's license must be submitted with the provider application for participation. Subsequent licensure must be provided when issued. 1. Subsequent license renewal must be forwarded to Provider Enrollment within 30 days of issue. If the renewal documents have not been received within the 30-day deadline, the provider will have an additional and final 30 days to comply.2. Failure to ensure that current licensure is on file with Provider Enrollment will result in termination from the Arkansas Medicaid Program.B. Provider must be enrolled in the Title XVIII (Medicare) Program.C. Provider must complete a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print the provider application (form DMS-652), the Medicaid contract (form DMS-653) and the Request for Taxpayer Identification Number and Certification (Form W-9).D. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid provider contract. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.E. The Visual Care provider must adhere to all applicable professional standards of care and conduct.201.110 Visual Care Providers in Arkansas and Bordering States Visual Care Program providers in Arkansas and the bordering states of Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas will be enrolled as routine services providers.
Routine Services Providers
A. Provider will be enrolled in the program as a regular provider of routine services.B. Reimbursement will be available for all visual care services covered in the Arkansas Medicaid Program.C. Claims must be filed according to Section 240.000 of this manual. This includes assignment of ICD-9-CM and HCPCS codes for all services rendered. 201.120 Visual Care Providers in States Not Bordering Arkansas A. Visual Care providers in states not bordering Arkansas are called closed-end providers because they may enroll in Arkansas Medicaid only after they have furnished services to an Arkansas Medicaid beneficiary and have a claim to file. View or print Provider Enrollment Unit contact information.A non-bordering state provider may download the provider manual and provider application materials from the Arkansas Medicaid website, www.medicaid.state.ar.us/lnternetSolution/Provider/Provider.aspx, and then submit the application and claim to the Medicaid Provider Enrollment Unit.
B. Closed-end providers remain enrolled for one year. 1. If a closed-end provider treats another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one year past the newer claim's last date of service, if the provider keeps the enrollment file current.2. During this enrollment period, the provider may file any subsequent claims directly to the Arkansas Medicaid fiscal agent.3. Closed-end providers are strongly encouraged to submit claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.201.200 Services to Beneficiaries with Refraction Visual care providers who accept a Medicaid beneficiary for an eye examination with refraction must follow these guidelines:
A. The provider will advise the beneficiary, prior to performing the exam, that he or she will not provide the glasses.B. The beneficiary will be given the choice to select a provider who will provide both services.C. If the beneficiary elects to have the examination, a written prescription for the glasses will be given or offered to the beneficiary post-examination.D. The prescriber cannot withhold the prescription pending Medicaid payment for the refraction.E. If the beneficiary is not satisfied with the frame selection or services provided, the provider will offer the beneficiary "freedom of choice" and give the beneficiary the prescription for glasses.202.000 Visual Care Records Providers are Required to Keep Visual care providers are required to keep the following records and, upon request, must immediately furnish the records to authorized representatives of the Division of Medical Services, the state Medicaid Fraud Control Unit, representatives of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services:
A. History and visual care examination on initial visit.B. Chief complaint on each visit.E. Treatment, including prescriptions.F. Signature or initials of visual care provider after each visit.G. Copies of hospital and/or emergency room records that are available to disclose services. 1. All records must be kept for five (5) years from the ending date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish these records upon request may result in sanctions being imposed.2. All documentation must be immediately made available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider's place of business. When a recoupment is necessary, no more than thirty (30) days will be allowed after the date of the recoupment notice in which additional documentation will be accepted. Additional documentation will not be accepted after the 30 days allowed after recoupment.3. Visual Care providers furnishing any Medicaid-covered good or service for which a prescription is required by law, by Medicaid rule, or both, must have a copy of the prescription for such good or service. The Visual Care provider must obtain a copy of the prescription within five (5) business days of the date the prescription is written.4. The Visual Care provider must maintain a copy of each relevant prescription in the Medicaid beneficiary's records and follow all prescriptions and care plans.203.000 Monitoring Performance of the Medicaid Optical Equipment Supplier
The Arkansas Medicaid Program uses a single optical laboratory selected through a competitive bid process to furnish eyeglasses for eligible Medicaid beneficiaries. The Medicaid Program's Medical Assistance Unit depends on visual care providers to assist in monitoring the performance of the contractor both in quality of product and timeliness of delivery. The following procedures must be followed:
A. The Medical Assistance Unit welcomes positive and negative comments regarding the optical laboratory's performance. All comments regarding the optical laboratory's performance must be made on the Vendor Performance Report. View or print the Vendor Performance Report. The provider will complete the Vendor Performance Report at any time a beneficiary verbally expresses dissatisfaction with their eyeglasses.B. Vendor Performance Reports should be mailed to the Division of Medical Services, Medical Assistance Unit. View or print the Division of Medical Services, Medical Assistance Unit contact information.C. The Medical Assistance Unit, upon receipt of the Vendor Performance Report, will log and investigate the complaint.D. A copy of the report is kept on file and may be a factor in awarding future contracts. To assist the Medical Assistance Unit in investigating your report, the following guidelines are suggested when submitting a Vendor Performance Report::
A. Agency and address - enter your name, address and phone numberB. Vendor and address - enter name and address of optical laboratoryC. Include the date the patient was examined and the date the claim and prescription were submittedD. Indicate the date the eyewear was deliveredE. Describe specific problems, e.g., poor quality (explain in detail), failure to deliver in a timely manner, unauthorized frame substitution, etc.F. Give name of the Medicaid beneficiary and ID numberG. If your staff has previously contacted the optical lab about a problem, note the date of contact, the name of the person who made the contact and the name of the persons contacted. Include any pertinent information related to the contact.Copies of the Vendor Performance Report may be obtained by calling the Division of Medical Services, Medical Assistance Unit. View or print the Division of Medical Services, Medical Assistance Unit contact information.
204.000 The Visual Care Provider's Role in the Child Health Services (EPSDT) Program
The Arkansas Medical Assistance Program includes a Child Health Service, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program for eligible individuals less than 21 years of age. The purpose of this program is to detect and treat health problems in their early stages.
If you are a Child Health Services (EPSDT) provider, please refer to the Child Health Services (EPSDT) provider manual for additional information.
Visual care providers interested in enrolling in the Child Health Services (EPSDT) Program should contact the Central Child Health Services Office. View or print contact information for the Central Child Health Services Office.
Visual care providers must bill Child Health Services (EPSDT) on the DMS-694 claim form using the proper Child Health Services (EPSDT) procedure codes found in the Child Health Services (EPSDT) provider manual. Ancillary charges, such as lab and X-ray, associated with Child Health Services (EPSDT) should be listed on the DMS-694. View a DMS-694 sample form.
Any enrolled Arkansas Medicaid provider rendering services not covered by the Arkansas Medicaid Program to a participant in the Child Health Services (EPSDT) Program who has been referred for services as a result of an EPSDT screen will be reimbursed for the services rendered if the services are medically necessary and permitted under federal Medicaid regulations.
Any Arkansas Medicaid provider may bill for non-covered services if the services are provided to a participant in the Child Health Services (EPSDT) Program who has been referred due to an EPSDT screen. The services must be medically necessary and permitted under federal Medicaid regulations.
When a provider performs a Child Health Services (EPSDT) screen and refers the patient to another provider for services not covered by Arkansas Medicaid, the referring provider must give the beneficiary a prescription for the non-covered services. The prescription must indicate the services being prescribed and state the services are being prescribed due to an EPSDT screen. In order for the non-covered service to be eligible for Medicaid payment, the referral documentation must be available for review. A provider who performs a Child Health Services (EPSDT) screen may also provide services resulting from the screen, if appropriate.
The prescription for services must be dated by the referring provider. The prescription for the non-covered service is acceptable if services were prescribed and the prescription is dated within the applicable periodicity schedule, not to exceed a maximum of 12 months.
211.000 Introduction The Arkansas Medicaid Program covers visual care services of Medicaid beneficiaries within restrictions set in federal and state guidelines. The following paragraphs are a general summary of the program coverage. Detailed coverage, prior authorization, reference information and other requirements may be found in those specific sections within this manual.
212.000 Contact Lens The Visual Care Program makes contact lenses available to eligible beneficiaries under the following guidelines:
A. All requests for contact lenses require prior authorization by the Medical Assistance Unit. (Refer to Section 220.000 of this manual for prior authorization procedures).B. Contact lenses are covered if either of the following conditions are exhibited by the patient: 2. Cataract (aphakia) patientsC. The following types of contact lenses are provided: 3. Toric lens to correct astigmatism5. Lenses for cataract patients8. Planned replacement lensD. Bifocal lenses are not covered.E. Upon completion of the visual analysis, the provider will forward a letter containing the following information to the Division of Medical Services, Medical Assistance Unit. View or print form DMS-0101.1. Patient's name, date of birth and Medicaid ID number4. Diagnosis and pathology5. Visual acuities without correction, with present correction and with best correction6. Power of patient's most recent prior prescription7. Medical justification for prescribing contacts8. Type of contacts requested, lens specifications, K reading, hard or soft conventional daily-wear contacts, disposable or planned replacement contacts9. Provider name, address and Medicaid provider numberF. The visual analysis is reimbursable even if the contact lenses are not authorized. All other services should be billed as a package deal and should include the following services:2. Supply and fitting of contact lens3. Contact lens care kit, including sterilizer4. Up to four follow-up visits to achieve maximum wearing time up to a period of six months. The patient will be responsible for payment of all other office visits after the four initial visits or six months, whichever comes first.G. A patient receiving contact lenses should have a pair of conventional glasses. If the current prescription of the patient's glasses is adequate, Medicaid will not furnish another pair. When the patient does not have a pair of conventional glasses or the current prescription is inadequate, a new pair will be furnished. If a new pair is needed, the provider must complete and submit Form DMS-26-V with a request for contact lens invoice. View a DMS-26-V sample form. The prescribing doctor will be paid one time for prescribing and verifying the prescription. At the time of the contact lens request, the provider should furnish the power of the patient's old prescription, if available.H. Neither insurance nor service contracts are provided by Medicaid. This is the beneficiary's responsibility.I. If the patient cannot wear the lens, it is the responsibility of the provider to notify Medicaid and reimburse the program 50 percent of Medicaid's payment for the contact lens package deal. Refund checks will be made payable to DHHS Accounts Receivable. View or print the DHHS Accounts Receivable contact information. An explanation of refund should be enclosed with the check identifying the patient name, Medicaid number, date of service and date of Medicaid payment. Even if the patient cannot wear the lens, once the billing has been submitted, the service will count against the patient's benefit limit.J. For beneficiaries age 21 and over, lens replacement will be covered for postoperative cataract (aphakia) patients only and will require prior authorization. For beneficiaries under age 21, lens replacement will be covered as needed. For these beneficiaries, prior authorization is required except for post-operative cataract (aphakia) patients. Medicaid will reimburse the lower of the amount billed or the Medicaid maximum allowable for each procedure. When billing, the provider should submit the charge for lens replacement only and should not include charges for professional service.K. Refer to Section 240.000 of this manual for the procedure codes, description of services and billing instructions for contact lens.L. Any questions regarding approval or denial of contact lens should be forwarded to the Division of Medical Services, Medical Assistance Unit, attention Visual Care Services. View or print Division of Medical Services, Medical Assistance Unit contact information.213.200 Coverage and Limitations of the Adult Program A. One visual examination and one pair of glasses are available to eligible Medicaid beneficiaries every twelve (12) months.1.I f repairs are needed, the eyeglasses must have been originally purchased through the Arkansas Medicaid Program in order for repairs to be made.2. All repairs will be made by the optical laboratory.B. One prescription services fee every 12 months from the last date of serviceC. Lens replacement as medically necessary with prior authorizationD. Lens power for single vision must be a minimum of:2. -0.75 axis 90 or 0.75 axis 180 cylinder or at any axisE. Tinted lenses, photogray lenses or sunglasses are limited to post-operative cataract or albino patientsF. Bifocals for presbyopia must have a power of +1.00 and any changes in bifocals must be in increments of at least +0.50G. Bifocal lenses are limited to:H. For beneficiaries who are eligible for both Medicare and Medicaid, see Section I for coinsurance and deductible information.I. Plastic or polycarbonate lenses only are covered under the Arkansas Medicaid Program.J. Low vision aids are covered on a prior authorization basis.K. Medicaid eligible beneficiaries with the exception of nursing home residents, who are 21 or older, will pay a $2.00 co-payment to the visual care provider for prescription services.L. Adult diabetics are eligible (with prior authorization) to receive a second pair of eyeglasses within the twelve month period if their prescription changes more than one diopter.M. One visual prosthetic device every 24 months from the last date of serviceN. Eye prosthesis and polishing services are covered with a prior authorization.O. Trifocals are covered if medically necessary with a prior authorization.P. Progressive lenses are covered if medically necessary with a prior authorization.Q. Contact lenses are covered if medically necessary with a prior authorization. Please refer to section 212.000 for contact lens guidelines.213.300 Exclusions in the Adult Program A. The Medicaid Program will not reimburse for replacement glasses, with the exception of post-cataract patients, which will require prior authorization.B. Lenses may not be purchased separately from the frames. If the beneficiary desires frames other than the frames approved by Medicaid, he or she will be responsible for the lenses also. Medicaid will reimburse the provider for the examination in these situations.C. Medicaid will not pay the prescription service charges in situations where the patient buys the eyeglasses.D. Medicaid does not cover charges incurred due to errors made by doctors or optical laboratories.E. Tinted lenses for cosmetics purposes are not covered.F. Glass lenses are NOT covered by Medicaid.214.100 Scope of the Under Age 21 Program The primary purpose of this program is for the screening, examination, diagnosis and treatment of conditions of the eye for the prescribing and fitting of eyeglasses, contact lenses and low vision aids for eligible beneficiaries under 21 years of age.
214.200 Coverage and Limitations of the Under Age 21 Program A. One examination and one pair of glasses are available to eligible Medicaid beneficiaries every twelve months.1. If repairs are needed, the eyeglasses must have been originally purchased through the Arkansas Medicaid Program in order for repairs to be made.2. If the glasses are lost or broken beyond repair within the twelve month benefit limit period, one additional pair will be available through the optical laboratory without a prior authorization requirement from the Division.3. All repairs and/or replacements will be made by the optical laboratory.B. Prescriptive and acuity minimums must be met before glasses will be furnished. Glasses should be prescribed only if the following conditions apply: 1. The strength of the prescribed lens (for the poorer eye) should be a minimum of -75D + 1.00D spherical or a minimum of .75 cylindrical or the unaided visual acuity of the poorer eye should be worse than 20/30 at a distance.2. Reading glasses may be furnished based on the merits of the individual case. The doctor should indicate why such corrections are necessary. All such requests will be reviewed on a prior approval basis.C. Plastic or polycarbonate lenses only are covered under the Arkansas Medicaid Program.D. When the prescription has met the prescriptive and acuity minimum qualifications, Medicaid will purchase eyeglasses through a negotiated contract with an optical laboratory.E. The eyeglasses will be forwarded to the doctor's office where he or she will be required to verify the prescription and fit or adjust them to the patient's needs.F. Eye prosthesis and polishing services require a prior authorization.G. Contact lenses are covered if medically necessary with a prior authorization. Please refer to section 212.000 for contact lens guidelines.H. Eyeglasses for children diagnosed as having the following diagnoses must have a surgical evaluation in conjunction with supplying eyeglasses: 3. Exotropia or vertical tropia4. Children between the ages of twelve (12) and twenty-one (21) exhibiting exotropia214.300 Exclusions in the Under Age 21 Program A. Tinted or plastic lenses for cosmetic purposesB. Frames other than the ones on contractC. Contact lenses for cosmetic purposesD. Contact lenses or eyeglasses obtained by means other than Medicaid216.000 Medical Procedures Billable by Optometrists Optometrists are allowed to bill for certain procedures for office medical services and special services previously payable only to physicians.
The office medical services provided by an optometrist will be limited to twelve visits per state fiscal year for individuals age 21 and over. The benefit limit will be used in conjunction with four other programs. These programs are physicians' services, medical services provided by dentists, rural health clinic services and certified nurse-midwife services. Beneficiaries will be allowed twelve visits per state fiscal year for office medical services furnished by an optometrist, medical services furnished by a dentist, physicians' services, rural health clinic services, certified nurse-midwife services or a combination of the five. Extensions beyond the twelve-visit limit may be provided if medically necessary. Office medical services for beneficiaries under age 21 in the Child Health Services (EPSDT) Program are not benefit limited. Procedure codes, description of services and special billing instructions are located in Section 240.000 of this manual.
All beneficiaries of vision and medical eye care may have direct access to optometrists as primary eye care providers, independent of the primary care provider (e.g., physician, Federally Qualified Health Center (FQHC), etc.).
232.000 Rate Appeal Process A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a program/provider conference and will contact the provider to arrange a conference if needed. Regardless of the program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the program/provider conference.
If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services, which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services (DHHS) Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
241.000 Introduction to Billing Visual care providers use the Visual Care DMS-26-V claim form or the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission. 242.110 Visual Procedure Codes The following services are covered under the Arkansas Medicaid Program.
Procedure Code | Required Modifier | Description | Coverage |
Under 21 | Over 21 |
DIAGNOSTIC AND ANCILLARY SERVICES |
S0620 | ROUTINE OPTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; NEW PATIENT This service must include the following: case history, general health observation, external exam of the eye and adnexa, ophthalmoscopic examination, determination of refractive state, basic sensorimotor and binocularity examination. It may also include initiation of diagnostic and treatment programs or referral. | yes | yes |
S0621 | - | ROUTINE OPTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; ESTABLISHED PATIENT | yes | yes |
This service must include the following: case history, general health observation, external exam of the eye and adnexa, ophthalmoscopic examination, determination of refractive state, basic sensorimotor and binocularity examination. It may also include initiation of diagnostic and treatment programs or referral. |
92340 | FITTING OF SPECTACLES, EXCEPT FOR APHAKIA: MONOFOCAL Fitting includes measurement of anatomical facial characteristics, the writing of laboratory specifications, and the final adjustment of the spectacles to the visual axes and anatomical topography. | yes | yes |
92370 | REPAIR AND REFITTING OF SPECTACLES Repair and refitting spectacles; except for aphakia | yes | yes |
99173 | UB | SCREENING TEST OF VISUAL ACUITY, QUANTITATIVE, BILATERAL This procedure must include at minimum three of the services listed under procedure code V0100. This code may not be billed in conjunction with procedure code V0100. | yes | yes |
CONTACT LENS SERVICES |
S0592 | COMPREHENSIVE CONTACT LENS EVALUATION This service must include the following: biomicroscopy, multiple ophthalmometry, case history, tear flow, measurement of ocular adnexa, initial tolerance evaluation, and may include other tests. This procedure does not include contact lens and should be billed in conjunction with other contact lens procedure codes. If billing this code, DO NOT bill S0620 or S0621. Contacts and glasses may be ordered using this code. | yes | yes |
S0512 | SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens) | yes W/PA | yes W/PA |
S0512 | SUPPLYING AND FITTING OF CONTACT LENS (GAS PERMEABLE) Spherical, aphakic, lenticular, toric, prism ballast (per lens) | yes W/PA | yes W/PA |
V2501 | UA | SUPPLYING AND FITTING OF KERATOCONUS LENS (HARD OR GAS PERMEABLE) - per lens | yes W/PA | yes W/PA |
S0512 | - | SUPPLYING AND FITTING OF MONOCULAR LENS (HARD OR GAS PERMEABLE)-per lens | yes W/PA | yes W/PA |
V2501 | U1 | SUPPLYING AND FITTING OF MONOCULAR LENS (SOFT LENS) -per lens | yes W/PA | yes W/PA |
S0512 | SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens) | yes W/PA | yes W/PA |
S0500 | - | DISPOSABLE CONTACTS (PER LENS) | Yes W/PA | W/PA |
LOW VISION SERVICES |
92002 | UB | LOWVISION EVALUATION | yes W/PA | yes W/PA |
SUPPLEMENTAL PROCEDURES |
92081 | - | VISUAL FIELD - Electronic or Goldmann | yes | yes |
92081 | - | VISUAL FIELD - Confrontation Perimetry | yes | yes |
MISCELLANEOUS SERVICES |
92100 | UB | TONOMETRY This procedure will only be covered when medically necessary. These conditions include, but are not limited to, diabetes, hypertension and age of the patient. | yes | yes |
V2623 | - | EYE PROSTHESIS Prosthetic eye, plastic, custom | yes W/PA | yes W/PA |
V2624 | " | POLISHING OF PROSTHESIS Polishing/resurfacing of ocular prosthesis | yes W/PA | yes W/PA |
92065 | - | ORTHOPTIC AND PLEOPTIC TRAINING WITH CONTINUING MEDICAL DIRECTION AND EVALUATION | yes W/PA | no |
92060 | SENSORIMOTOR EXAMINATION Wth multiple measurements of ocular deviation (eq, restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure). | yes W/PA | no |
96111 | DEVELOPMENTAL TESTING Extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report. | Yes W/PA | no |
CONTACT LENS REPLACEMENT |
92326 | " | HARD LENS (PER LENS) This procedure code does not include a professional fee. | yes W/PA | no |
92326 | " | SOFT LENS (PER LENS) This procedure code does not include a professional fee. | yes W/PA | no |
92326 | " | GAS PERMEABLE (PER LENS) This procedure code does not include a professional fee. | yes W/PA | no |
92326 | - | APHAKIC LENS Post-operative cataract. | Yes W/PA | yes W/PA |
V2799 | - | UNSPECIFIED PROCEDURE | yes | yes |
242.410 Billing for Medicare/Medicaid Dually-Eligible Beneficiaries If Medicare denies a claim for services provided to a beneficiary eligible for both Medicare and Medicaid, the claim will not cross over to Medicaid automatically. Therefore, the Visual Care claim form DMS-26-V should be submitted to EDS along with the Explanation of Medicare Benefits (EOMB) explaining the reason for Medicare's denial.
NOTE: A copy of the Medicare EOMB must be attached to the claim and must match the dates of service on the claim form.
Medicare/Medicaid crossover claims are discussed in Section III of this manual.
243.150 Office Medical Services The office medical services provided by an optometrist are limited to twelve (12) visits per state fiscal year (July 1 through June 30) for beneficiaries age 21 and older. The benefit limit will be used in conjunction with four other programs: physicians' services, medical services provided by dentists, rural health clinic services and certified nurse-midwife services. Beneficiaries will be allowed twelve visits per state fiscal year for office medical services furnished by an optometrist, medical services furnished by a dentist, physicians' services, rural health clinic services and certified nurse-midwife services or a combination of the five. Extensions beyond the twelve-visit limit may be provided if medically necessary. Office medical services for beneficiaries underage 21 in the Child Health Services (EPSDT) Program are not benefit limited.
Office medical services covered in the Visual Care Program are limited to the following procedure codes:
92002 | 92004 | 92012 | 92014 |
99201 | 99202 | 99203 | 99204 |
99205 | 99211 | 99212 | 99213 |
99214 | 99215 |
016.06.07 Ark. Code R. 003