Section 471-24-005 - BILLING AND PAYMENT FOR VISUAL CARE SERVICES005.01BILLING.005.01(A)GENERAL BILLING REQUIRMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in this 471 NAC 24, the billing requirements in 471 NAC 24 will govern.005.01(B)SPECIFIC BILLING REQUIREMENTS.005.01(B)(i)BILLING REQUIRMENTS. Providers must bill Nebraska Medicaid for visual care services on the appropriate claim form or electronic format.005.01(B)(ii)USUAL AND CUSTOMARY CHARGE, The provider or their authorized agent must submit the provider's usual and customary charge for services rendered. The provider's total charge for services may not exceed the provider's usual and customary charge.005.01(B)(iii)NON-COVERED SERVICES. If the provider furnishes items or services not covered by Nebraska Medicaid, on a private basis, the individual must pay the full charge of the items or services. The provider is prohibited from billing Nebraska Medicaid for any portion of the non-covered items or services.005.01(B)(iv)BILLING THE RECIPIENT FOR FRAMES. Charges for frames purchased by a recipient on a private pay basis must include the associated fitting charge.005.01(B)(v)BILLING FOR LENSES.005.01(B)(v)(1)SCRATCH RESISTANT COATING. The cost for the scratch; resistant coating must be included in the lens cost and is not billed under a separate procedure code. The laboratory invoice must indicate that the scratch resistant coating was provided. Nebraska Medicaid does not require that lenses with scratch resistant coating be warranted:005.01(B)(v)(2)BILLING THE RECIPIENT.005.01(B)(v)(2)(a)LENSES. Charges for lens purchased by a recipient on a private pay basis must include the associated fitting charge.005.01(B)(v)(2)(b)SPECIAL LENS FEATURES AND LAB PROCEDURES- If non-covered lens features or lab procedures other than non-covered tints are desired by recipients, they must be purchased on a private pay basis.005.01(B)(v)(2)(c)LENS TINTS. The recipient can be billed for non-covered lens tints under the following conditions: (i) The recipient has been notified by the provider in writing that Nebraska Medicaid will not cover the lens tint: and(ii) The recipient voluntarily agrees to reimburse the provider for the lens tint on a private pay basis.005.02PAYMENT.005.02(A)GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that payment regulations in 471 NAC 3 conflict with payment regulations outlined in 471 NAC 24, the payment regulations in 471 NAC 24 will govern.005.02(B)SPECIFIC PAYMENT REQUIRMENTS.005.02(B)(i)REIMBURSEMENT. Nebraska Medicaid pays for covered visual care services in an amount equal to the lesser of: (1) The provider's submitted charge: and(2) The allowable amount for the procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.005.02(B)(ii)MEDICARE AND NEBRASKA MEDICAID CROSSOVER CLAIMS. For information on the payment of Medicare and Nebraska Medicaid crossover claims, see 471 NAC. 3.005.02(B)(iii)COPAYMENT. For Nebraska Medicaid copayment requirements, see 471 NAC 3.005.02(B)(iv)PAYMENTS FOR EYE EXAMS. Eye examinations provided primarily for the purpose of prescribing, fitting, or changing eyeglasses for refractive errors are reimbursed at the Nebraska Medicaid fee schedule allowable for intermediate level general ophthalmological services, as defined in the American Medical Association's Physicians' Current Procedural Terminology (CPT). Determination of the refractive state is reimbursed separately from examination services.005.02(B)(v)PAYMENTS FOR VISION THERAPY TRAINING. Payment for vision therapy training includes all equipment and supplies necessary for home use.471 Neb. Admin. Code, ch. 24, § 005
Repealed effective 12/14/2016.Amended effective 12/27/2021