Or. Admin. Code § 410-140-0200

Current through Register Vol. 64, No. 1, January 1, 2025

Section 410-140-0200 - Glasses

(1) The Division covers the fitting of glasses and the refitting and repair of glasses only when glasses and replacement parts are purchased from:

(a) The Division's contractor;

(b) Any visual materials supplier when the member has primary Medicare coverage or Third Party Liability (TPL) coverage and the glasses were a Medicare-covered or TPL-covered benefit.

(2) The Division covers glasses for:

(a) Eligible adults (age 21 and older) once (1) every 24 months;

(b) Members once within 120 days following cataract surgery. When ordering glasses from contractor, the date of surgery must be listed on the order form;

(c) Eligible children (birth through age 20) without limitation when it is documented in the physician's or optometrist's clinical record as medically appropriate.

(3) Fitting of glasses for:

(a) Eligible adults (age 21 years and older) is limited to once (1) every 24 months, except when dispensing glasses within 120 days of cataract surgery;

(b) Eligible children (birth through age 20) only when documented in the member's record as medically necessary and medically appropriate.

(4) Periodic adjustment of frames and tightening of screws is included in the dispensing fee and is not separately reimbursed.

(5) The Division accepts either the date of order or date of dispensing as the date of service on claims. Glasses must be dispensed prior to billing the Division, except under the following conditions:

(a) Death of the member prior to dispensing; or

(b) Member failure to pick up ordered glasses. Documentation in the member's record must show that the provider made serious efforts to contact the member.

(6) Providers must keep a copy of the delivery invoice included with all parts orders in the member's records or document the delivery invoice number in the member's records for all repair and refitting claims.

(7) Fitting of spectacle mounted low vision aids, single element systems, telescopic or other compound lens systems are not covered.

(8) All frames have a limited warranty. Check specific frame styles for time limits. All defective frames must be returned to the contractor.

(9) It is the provider's responsibility to verify member eligibility and benefit coverage pursuant to OAR 410-120-1140, prior to submitting a visual materials order to SWEEP optical.

(10) If a member receives services under section (2)(b) of this rule:

(a) The Division may require a Prior Authorization (PA) for certain covered services or items before the service may be provided and before payment is made; and

(b) Providers needing materials and supplies are required to order those directly from SWEEP Optical, except when the OHP member has primary Medicare coverage or Third Party Liability (TPL) coverage (Refer to OAR 410-120-0000).

(11) Frames for display purposes may be purchased from the contractor for the same price as frames for glasses negotiated by the Oregon Department of Administrative Services:

(a) A case may not be provided with display frames; and

(b) Quantity, style, size, and color of frames must be specified in the order for display frames.

(12) Costs for the following are included in reimbursement for the lens and are not separately reimbursed by the Division:

(a) Scratch coating;

(b) Prism;

(c) Special base curve; and

(d) Tracings.

(13) If a frame cannot be located in the contractor's catalog at www.sweepoptical.com that meets the medical needs of the member:

(a) Providers shall contact contractor for assistance with locating a frame to meet the member's need; and

(b) Frames not included in the contract between the Division and contractor may be purchased through contractor with PA.

(14) Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.

Or. Admin. Code § 410-140-0200

AFS 75-1989, f. & cert. ef. 12-15-89; HR 15-1992, f. & cert. ef. 6-1-92, Renumbered from 461-018-0250; HR 37-1992, f. & cert. ef. 12-18-92; HR 1-1996, f. 1-12-96, cert. ef. 1-15-96; HR 15-1996(Temp), f. & cert. ef. 7-1-96; HR 26-1996, f. 11-29-96, cert. ef. 12-1-96; OMAP 11-2002, f. & cert. ef. 4-1-02; OMAP 56-2002, f. & cert. ef. 10-1-02; OMAP 60-2003, f. 9-5-03, cert. ef. 10-1-03; DMAP 44-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14; DMAP 7-2016, f. 2-23-16, cert. ef. 3/1/2016; DMAP 74-2022, amend filed 09/23/2022, effective 9/25/2022; DMAP 52-2024, minor correction filed 02/21/2024, effective 2/21/2024; DMAP 127-2024, amend filed 10/08/2024, effective 10/8/2024

Tables referenced are not included in rule text. Click here for PDF copy of table(s).

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025 & 414.065