N.J. Admin. Code § 10:54-5.45

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:54-5.45 - Vision care services

(a) The Division recognizes vision care services, and optical appliances and services provided only by the following eligible providers, within the restrictions of their respective licensure or requirements in the state in which they are located:

1. An ophthalmologist means a licensed physician who is a diplomate of the American Board of Ophthalmology or who has been recognized by the New Jersey Medicaid/NJ FamilyCare program as a specialist in ophthalmology;

2. An optometrist means a person who is licensed by the New Jersey State Board of Optometry to engage in the practice of optometry, or similarly licensed by a comparable agency of the state in which he or she performs such functions;

3. An optician means a person licensed by the New Jersey State Board of Examiners of Ophthalmic Dispensers and Ophthalmic Technicians, or similarly licensed by a comparable agency of the state in which he or she performs such functions;

4. A recognized ocularist who provides artificial eyes, upon the recommendation of a prescribing practitioner. (See the Vision Care Services Chapter at N.J.A.C. 10:62-3);

5. An independent clinic approved by the Division to render eye care services;

6. Hospital meeting the definition of an approved general hospital, approved special hospital, or approved private or state and county governmental psychiatric hospital, as adhering the conditions of participation as described in N.J.A.C. 10:52, Hospital Services Manual; or

7. An ophthalmologist, optometrist, optician and ocularist practicing in another state who are duly licensed or meet the requirements of the state in which they are practicing with regard to dispensing optical appliances.

(b) Covered professional (ophthalmologist and optometrist) vision care services include office visits for evaluation and management, comprehensive eye examinations, low vision examinations, low vision work-ups, vision training work-ups, and vision training program visits.

1. When providing professional vision care services, the ophthalmologist and optometrist shall comply with N.J.A.C. 10:62.

(c) For Medicaid/NJ FamilyCare purposes, prior authorization shall be required for a low vision work-up, vision training work-up and vision training. The Vision Care Services Chapter, at 10:62-2.5, lists the optical appliances that require prior authorization.

1. Prior authorization (Form MC-9(A)) shall be requested in writing from the Vision Care Services, Office of Utilization Management, Division of Medical Assistance and Health Services, Mail Code #16, PO Box 712, Trenton, New Jersey 08625-0712.

N.J. Admin. Code § 10:54-5.45

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In the introductory paragraph of (a), substituted a colon for a period at the end; in (a)1 and the introductory paragraph of (c), inserted "/NJ FamilyCare"; in (a)1, (a)2 and (a)3, substituted a semicolon for a period at the end; in (a)4, inserted "the" preceding "Vision", "at" for a comma following "Chapter" and ");" for ".)"; in (a)5, deleted "or a" from the end; in (a)6, deleted "the Hospital Services Chapter in" preceding "N.J.A.C." and substituted ", Hospital Services Manual; or" for a period at the end; in (a)7, deleted a comma following "optician" and substituted "state" for "State"; and in the introductory paragraph of (c), deleted a comma following "work-up" and inserted a comma following "Chapter".