Okla. Admin. Code § 317:30-5-431

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-431 - Coverage by category

Payment is made to optometrists as set forth in this Section.

(1)Adults. Payment can be made for medical services that are reasonable and necessary for the diagnosis and treatment of illness or injury up to the patient's maximum number of allowed office visits per month.

(A) There is no provision for routine eye exams, examinations for the purpose of prescribing glasses or visual aids, determination of refractive state, treatment of refractive errors, or purchase of lenses, frames, or visual aids. Payment is made for treatment of medical or surgical conditions which affect the eyes. Prior to providing non-covered services, providers must notify members in writing of those services not covered by SoonerCare. Determination of refractive state or other non-covered services may be billed to the patient if properly notified.

(B) The global surgery fee allowance includes preoperative evaluation and management services rendered the day before or the day of surgery, the surgical procedure, and routine postoperative period. Co-management for cataract surgery is filed using appropriate CPT codes, modifiers and guidelines. If an optometrist has agreed to provide postoperative care, the surgeon's information must be in the referring provider's section of the claim.

(C) Payment for laser surgery to optometrist is limited to those optometrists certified by the Board of Optometry as eligible to perform laser surgery.

(2)Children. Eye examinations are covered when medically necessary. Determination of the refractive state is covered when medically necessary.

(3)Individuals eligible for Part B of Medicare. Payment is made utilizing the Medicaid allowable for comparable services.

Okla. Admin. Code § 317:30-5-431

Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 17 Ok Reg 3354, eff 8-1-00 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2922, eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 23 Ok Reg 2463, eff 6-25-06; Amended at 24 Ok Reg 2824, eff 5-1-07 (emergency); Amended at 25 Ok Reg 653, eff 2-1-08 (emergency); Amended at 25 Ok Reg 2634, eff 7-25-08