016.06.17 Ark. Code R. 008

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

Rule 016.06.17-008 - Visual 2-16

Section IIVisual Care

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 (12) 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 (12)-month benefit limit period, one additional pair will be available through the optical laboratory. After the first replacement pair, any additional pair will require prior authorization. There will be no co-payment assessed for replacement glasses requiring prior authorization.

3. All replacements will be made by the optical laboratory and the doctor's office may make repairs only when necessary.

4. EPSDT beneficiaries will have no co-pays. ARKids First-B beneficiaries will be assessed a $10.00 co-pay. All co-pays will be applied to examination codes rather than to tests or procedures.

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 .OOD 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 fonrt/arded to the doctor's office where he or she will be required to verify the prescripfion 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.

1. Ptosis (droopy lid)

2. Congenital cataracts

3. Exotropia or vertical tropia

4. Children between the ages of twelve (12) and twenty-one (21) exhibiting exotropia

I. Prior authorized orthoptic and/or pleoptic training (procedure code 92065) may be performed only in the office of a licensed optometrist or ophthalmologist for Medicaid eligible children ages twenty (20) and under and for CHIP eligible children ages eighteen (18) and under.

1. The initial prior authorization request must include objective and subjective measurements and tests used to indicate diagnosis.

2. The initial prior autlnorization approved for tinis treatment will consist of sixteen (16) treatments in a twelve (12)-month period with no more than one treatment per seven (7) calendar days.

3. An extension of benefits may be requested for medical necessity.

4. Requests for extension of benefits must include the initial objective and subjective measures with diagnosis along with subjective and objective measures after the initial sixteen (16) treatments are completed to show progress and the need for, or benefit of, further treatment.

5. For a list of diagnoses that are covered for orthoptic and/or pleoptic training (View ICD Codes.).

J. Prior authorized sensorimotor examination (procedure code 92060) may be performed only in the office of a licensed optometrist or ophthalmologist for Medicaid eligible children ages twenty (20) and under and for CHIP eligible children ages eighteen (18) and under who have received a covered diagnosis based on specific observed and documented symptoms.

1. Benefit limit of one (1) sensorimotor examination in a twelve (12) month period.

2. An extension of benefits may be requested for medical necessity.

3. For a list of diagnoses that are covered for sensorimotor examination (View ICD Codes.).

K. Prior authorized developmental testing (procedure code 96111) may be performed only in the office of a licensed optometrist or ophthalmologist for Medicaid eligible children ages twenty (20) and under and for CHIP eligible children ages eighteen (18) and under who have received a covered diagnosis based on specific observed and documented symptoms.

1. Benefit limit of one (1) developmental tesfing in a twelve (12) month period.

2. An extension of benefits may be requested for medical necessity.

3. For a list of diagnoses that are cdvered for developmental testing (View ICD Codes.).

221.000 How to Obtain Prior Authorization

To obtain prior authorization to provide services not ordinarily covered, the provider must submit in wrifing a brief, yet descriptive, account of the services requested and, if possible, the procedure code to be used when billing. All supportive information available should be submitted.

Send all requests for prior authorization to the Division of Medical Services, Medical Assistance Unit. View or print Division of Medical Services. Medical Assistance Unit contact information.

Ail requests for prior authorization will be reviewed by the visual care consultants. All or part of the services requested may be approved. Approval or denial of the services requested will be given in wrifing. In no event will prior authorizafion be given over the telephone.

The approval of the request for prior authorization will be signed by the visual care consultants or authorized personnel and assigned a prior authorizafion control number. The prior authorization control number must be indicated on the claim.

Prior Authorization (PA) requests should be submitted and approved PRIOR to the delivery of any requested service that requires prior authorization. PA requests received retrospectively (after the date of service of the requested service), will be evaluated for medical necessity and if approved will allow payment for related claims (subject to timely filing rules) perfonned prior to submission of tine PA request. PLEASE NOTE: A provider wiio performs a service tiiat requires a prior autiiorization before receiving PA approval is at risk for non-payment for tine service in tine event tiiat tiie retrospectively submitted PA request is denied.

242.110 Visual Procedure Codes

The following services are covered under the Arkansas Medicaid Program. "W/PA" means that a service requires prior authorization.

Procedure Code	Required Modifier	Description	Coverage
			Under 21	Over 21
DIAGNOSl	IC AND ANCI	LLARY SERVICES
S0620	ROUTINE OPTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION: NEW PATIENT This service must include the followina: 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 This service must include the followina: 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
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 W/PA

99173	UB	SCREENING TEST OF VISUAL ACUITY. QUANTITATIVE. BILATERAL This procedure must include at a minimum three components listed under procedure code S0620 or S0621. This code may not be billed in conjunction with procedure code S0620 or S0621.	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.	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
S0512	SUPPLYING AND FITTING OF CONTACT LENS (GAS PERIVIEABLE) 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	yes W/PA
LOW VISION SERVICES
92002	OPHTHALMOLOGICAL SERIVICES: Medical examination and evaluation with initiation of diagnostic and treatment program; intemnediate, new patient	yes	yes

SUPPLEMENTAL PROCEDURES
92081 - VISUAL FIELD EXAMINATION Unilateral or bilateral, with interpretation and report; limited examination	yes	yes
92082 - VISUAL FIELD EXAMINATION Unilateral or bilateral, with interpretation and report; intermediate examination	yes	yes
92083 - VISUAL FIELD EXAMINATION Unilateral or bilateral, with interpretation and report; extended examination	yes	yes
MISCELLANEOUS SERVICES
92100 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
92065 ORTHOPTIC AND PLEOPTIC TRAINING WITH CONTINUING MEDICAL DIRECTION AND EVALUATION	yes W/PA	no
92060 SENSORIMOTOR EXAMINATION With multiple measurements of ocular deviation (e.g., 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	yes W/PA
92326 - SOFT LENS (PER LENS) This procedure code does not include a professional fee.	yes W/PA	yes W/PA
92326 - GAS PERMEABLE (PER LENS) This procedure code does not include a professional fee.	yes W/PA	yes W/PA
92326 - APHAKIC LENS Post-operative cataract.	yes W/PA	yes W/PA
V2799 - UNSPECIFIED PROCEDURE	yes	yes
EYE PROSTHESIS

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
V2625 -	ENLARGEMENT of ocular prosthesis	yes W/PA	yes W/PA
V2626 -	REDUCTION of ocular orosthesis	yes W/PA	yes W/PA

016.06.17 Ark. Code R. 008

6/20/2017