Or. Admin. Code § 410-140-0400

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-140-0400 - Contractor Services

(1) The Division of Medical Assistance Programs (Division) contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to provide vision materials and supplies. Providers needing materials and supplies must order those directly from the contractor, except when the Oregon Health Plan (OHP) member has primary Medicare coverage or Third Party Liability (TPL) coverage. See OAR 410-140-0080.

(2) The Division contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to buy vision materials and supplies, excluding contact lenses. All frames, lenses, and miscellaneous items must be provided:

(a) Only by the contractor, unless the member has primary Medicare coverage or Third Party Liability (TPL) coverage; or

(b) By any visual materials supplier when the member has primary Medicare coverage for a Medicare covered item or TPL coverage for a TPL-covered item.

(3) The contractor's responsibilities:

(a) Forward Division PA approval to the provider;

(b) Order specifications:

(A) The contractor shall provide the order as specified by the ordering provider;

(B) The contractor shall be responsible for all shipping and handling charges for shipments to the provider via United States mail or United Parcel Service for all returned orders that are not to the specifications of the order or that are damaged in shipping;

(C) The contractor may not accept initial orders via telephone. The contractor shall accept telephone calls or faxed messages regarding orders that are not made to specifications;

(D) When the contractor is notified of an item to be returned due to the item not being made to specifications in the original order, the contractor shall begin remaking the product as soon as they are notified, whether or not they have received the item being returned. (The ordering provider shall return the original product to the contractor with a written explanation of the problem and indicate the date they notified the contractor to remake the order.);

(c) Original order delivery:

(A) Delivery Date: The contractor shall deliver the original order of materials and supplies to the ordering provider within seven business days of the date the order is received;

(B) Delay: In the event of a delay in manufacturing or delivery, the contractor shall:

(i) Notify the ordering provider within two (2) business days of receipt of the order;

(ii) Include a description of the order, the reason for delay and the revised time of completion and delivery; and

(C) Special Orders: Delivery of special-order frames and lenses may exceed the required delivery time. In this event, the contractor shall provide the ordering provider with notice of the anticipated delay, give the ordering provider a projected delivery date, and document the actual delivery time for future reference.

(4) 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.

(5) The contractor may use the date of order as the date of service (DOS) but may not bill the Division until the order has been completed and shipped.

(6) The contractor shall bill the Division using Health Care Common Procedure Coding System (HCPC) Codes listed in the contract agreement. Payment shall be at contracted rates.

(7) The contractor shall include eyeglass cases with every frame. Cases may not be included in orders for only lenses, temples or frame fronts.

(8) Frame Displays: 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.

(9) Contractors shall have unisex frame styles available and shall allow members to choose any frame regardless of category listed.

(10) Regardless of verification received via phone or electronic sources, the contractor may not fill orders for members who do not have coverage or have met their vision benefit. See OAR 410-140-0140 Vision Services Coverage and Limitations. When glasses are ordered and the member has met their vision benefit for the time period:

(a) The Division shall reimburse the provider for the exam only if the member is not an established member of the provider and the member is currently a fee-for-service (FFS) member with vision benefits. See OAR 410-140-0050 Eligibility and Benefit Coverage;

(b) The provider needs to contact the member's Managed Care Entity (MCE) if the member is enrolled with an MCE that contracts with SWEEP Optical. The contractor applies vision limitations included in rule, regardless of changes to a member's enrollment status.

(11) Providers must:

(a) Verify the member's eligibility and benefit coverage prior to submitting vision material orders to the contractor;

(b) Obtain PA from the Division for items requiring PA prior to placing a vision materials order;

(c) Comply with the contractor's order submission requirements, as outlined in the Visual Services Supplemental Information Guide found at Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;

(d) Submit prescription or order to the contractor upon notification of PA approval from the contractor; and

(e) Pay SWEEP Optical for any services, materials, and supplies provided by SWEEP Optical to a member who is not eligible for items. SWEEP Optical may not sell materials and supplies for non-eligible members at the State Contracted Price.

(12) The contractor shall:

(a) Forward Division PA approval to the provider;

(b) Order specifications:

(A) The contractor shall provide the order as specified by the ordering provider;

(B) The contractor shall pay for all shipping and handling charges for shipments to the provider via United States mail or United Parcel Service for all returned orders that do not meet the order specifications or that are damaged in shipping;

(C) The contractor may not accept initial orders via telephone. The contractor shall accept telephone calls or faxed messages regarding orders that do not meet specifications;

(D) When the contractor is notified of an item to be returned because the item was not made to specifications in the original order, the contractor shall begin remaking the product as soon as they are notified, whether or not they have received the item being returned. The ordering provider shall return the original product to the contractor with a written explanation of the problem and indicate the date they notified the contractor to remake the order;

(c) Original order delivery:

(A) The contractor shall deliver the original order of materials and supplies to the provider within ten (10) business days of the date the order is received;

(B) In the event of a delay in manufacturing or delivery, the contractor shall:

(i) Notify the ordering provider within two (2) business days of receipt of the order;

(ii) Include a description of the order, the reason for delay, and the revised time of completion and delivery.

(C) Delivery of special-order frames and lenses may exceed the required delivery time. In this event, the contractor must provide the ordering provider with notice of the anticipated delay, provide a projected delivery date, and document the actual delivery time.

(13) The contractor:

(a) May use the date of order as the date of service (DOS) but may not bill the Division until the order has been completed and shipped;

(b) Shall bill the Division using Health Care Common Procedure Coding System (HCPC) Codes listed in the contract agreement. Payment shall be at contracted rates;

(c) Shall include eyeglass cases with every frame. Cases may not be included in orders for only lenses, temples, or frame fronts;

(d) Shall have unisex frame styles available and shall allow members to choose any frame regardless of category listed;

(e) Is not responsible if the Division determines the documentation in the member's record does not allow for the service pursuant to limitations indicated set forth in the administrative rules.

(14) The contractor and the Division may not pay for costs, expenses, or any required rework due to errors by the provider.

(15) The following services do not require PA, are subject to strict limitations, and require the physician or optometrist to submit appropriate documentation to contractor:

(a) Replacement parts for non-contracted frame styles are limited to frames purchased with PA approval;

(b) Tints and photochromic lenses are limited to members with documented albinism and pupillary defects. Documentation provided to contractor shall include the most appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code selected by a physician or optometrist;

(c) Other medically necessary items for a contract frame, when a member has a medical condition that requires the use of a specialty temple, nose pieces, head strap frame;

(d) Nonprescription glasses are limited to members who do not require any correction in one eye and where there is blindness in one eye. The purpose of this exception is to offer maximum protection for the remaining functional eye;

(e) High Index Lenses:

(A) Power is +/- 10 or greater in any meridian in either eye; or

(B) Prism diopters are 10 or more diopters in either lens;

(f) Polycarbonate lenses are limited to the following populations:

(A) Eligible children (birth through age 20);

(B) Members with developmental disabilities; and

(C) Members who are blind in one eye and need protection for the other eye, regardless of whether a vision correction is required.

(16) Regardless of verification received via phone or electronic sources, the contractor may not fill orders for members who do not have coverage or have met their vision benefit. When glasses are ordered and the member has met their vision benefit for the time period:

(a) The Division shall reimburse the provider for the exam only if the member is not an established member of the provider and the member is currently a FFS member with vision benefits;

(b) The provider shall contact the member's PHP or CCO if the member is enrolled with a PHP or CCO that contracts with SWEEP Optical. The contractor shall apply vision limitations pursuant to Division rules, regardless of changes to a member's enrollment status. The provider shall contact the member's PHP or CCO with the last date of service. The PHP or CCO shall determine if they may allow for an additional supply of glasses. If the member is an established member, regardless of incomplete information through phone or electronic verification systems or SWEEP Optical, the provider shall inform the PHP or CCO of the last date of service.

(17) 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 § 410-140-0400

AFS 75-1989, f. & cert. ef. 12-15-89; HR 37-1992, f. & cert. ef. 12-18-92, Renumbered from 461-018-0300; HR 15-1994, f. & cert. e.f 3-1-94; HR 5-1995, f. & cert. ef. 3-1-95; HR 1-1996, f. 1-12-96, cert. ef. 1-15-96; OMAP 44-2001, f. 9-24-01 cert. ef. 10-1-01; OMAP 61-2005, f. 11-29-05, cert. ef. 12-1-05; DMAP 21-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 33-2011, f. 12-5-11, cert. ef. 12-6-11; DMAP 26-2014, f. 4-29-14, cert. ef. 5-8-14; DMAP 57-2018, minor correction filed 05/25/2018, effective 5/25/2018; DMAP 55-2024, minor correction filed 02/21/2024, effective 2/21/2024; DMAP 127-2024, amend filed 10/08/2024, effective 10/8/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025, 414.065 & 279A.140