Optical services are covered for all eligible MHCP members.
MHCP purchases eyeglasses (frames and lenses) via a volume purchase contract with Classic Optical Laboratories, Inc. Only frames and lenses from the contract vendor will be covered for MHCP members.
Contact Classic Optical for frame sample kits, order form, or ordering assistance using any of the following methods:
Providers may dispense non-contract eyeglasses only if one of the following exceptions applies:
The following MHCP enrolled providers may dispense eyeglasses and perform vision services within their scope of practice:
Refer to Provider Enrollment for additional detailed enrollment information.
Provider Type Home Page Links
Eyeglasses and vision care services are covered for eligible MHCP members who require vision correction. See Health Care Programs and Services for specific program coverage.
It is the responsibility of the provider to verify eligibility of the member before providing services or ordering eyeglasses. Use the MN–ITS Interactive Eligibility Request (PDF) or 270 transaction to determine eligibility.
Keep documentation of medical necessity in the member’s medical records. The following services are covered when medically necessary and coverage criteria are met:
Contact lenses are covered without authorization if prescribed for aphakia, keratoconus, or aniseikonia and for bandage lenses. All other diagnoses or conditions require authorization for contact lens services and supplies.
For bilateral prescribing and fitting of bandage and therapeutic lenses (92071 and 92072), bill two units on one line with modifier 50. Claims must include an appropriate diagnosis.
For bilateral prescribing and fitting of contact lenses, , use modifier 52 when prescribing and fitting one eye. Aphakia codes 92310 and 92314 do not require a modifier.
Contact lenses: S0500, V2500-V2599. One unit = one contact lens. Planned replacement contact lenses may be dispensed as multi-packs. The following dispensing limits apply:
Type of Contact Lens
Disposable contact lens
1-month supply, up to 30 per eye per dispensing
PMMA, gas permeable, gas impermeable contact lens
2 units (1 per eye) per dispensing
Hydrophilic contact lens
2 units (1 per eye) per dispensing
MHCP does not have prior authorization requirements for eyeglass benefits. Services not listed are not available through the eyeglasses vision program.
Eyeglasses and related supplies must meet the following requirements:
MHCP has approved approximately 200 eyeglass frames for inclusion in the volume purchase contract. The contract vendor will provide one frame sample kit at no cost to each actively enrolled MHCP optical provider upon request. Each frame sample kit will include up to 48 frames in a variety of sizes, shapes and colors, and will include a limited selection of deluxe frames. Enrolled providers who wish to offer a wider selection of frames may purchase approved frames directly from the contract vendor at the contract price.
All eligible MHCP members may select any approved standard frame. Members under 21 years old and adult members with cognitive disabilities or seizure disorders may select approved deluxe frames. When a deluxe frame is ordered for a member aged 21 or older, the dispensing provider must include an appropriate diagnosis on the order. The contract vendor must include an appropriate diagnosis code on the claim. Direct questions about inclusion of a specific diagnosis to MHCP.
Members may select approved frames without lenses when purchasing noncovered lenses. The dispensing provider must be able to mount the noncovered lenses in the frames. The dispensing provider must clearly inform the member that the frames will be covered when ordered from the contract vendor, but that all costs associated with the noncovered lenses and mounting of the lenses will be the member’s responsibility.
Members with medical conditions that may be affected or aggravated by bright or changing light conditions may require specialty lenses, including tinted, U-V, polarized, or photochromatic lenses. When specialty lenses are ordered, the dispensing provider must include an appropriate diagnosis on the order. The contract vendor must include an appropriate diagnosis on the claim. Specialty lenses are covered for members with albinism, achromatopsia, aniridia, blue cone monochromatism, cystinosis, or retinitis pigmentosa. Direct questions about coverage of specialty lenses for other diagnoses to MHCP.
Members may request covered lenses for frames they own. The dispensing provider must clearly inform the member that if the contract vendor determines that mounting the lenses in the member-owned frames might reasonably be expected to damage the frames, the lenses will not be mounted and the frames will be returned to the dispensing provider for return to the member. If the member is purchasing nonapproved frames for use with covered lenses, the dispensing provider must clearly inform the member of any applicable return policies. The dispensing provider is not required to accept member-owned frames for transmittal to the contract vendor if their normal business practice would not include placing lenses in those frames.
Vision providers may dispense a new pair of eyeglasses when one or more of the following reasons for medical necessity are met:
Keep documentation of medical necessity for the above situations in the member’s medical record. The reason for the replacement must be included on the order when new eyeglasses are ordered from the contract vendor.
MHCP will pay for repairs to member’s eyeglasses when not covered under warranty even if the eyeglasses were not purchased through MHCP if the repair is cost effective.
Eyeglasses purchased through the volume purchase contract may be sent to the contract vendor for repairs, or may be repaired by the dispensing provider.
Refer to the Billing section when ready to submit a claim.
Refer to the following criteria for coverage:
The physician monitoring progress may bill for a limited examination in addition to the orthoptic or pleoptic training. Document in the medical record the physician saw the recipient and performed the necessary procedures for a limited examination. Examinations to evaluate visual therapy are limited to one per week.
The following services are not covered:
All contact lenses codes S0500 and V2500-V2599 and Contact Lenses Treatment Services codes 92070 and 92310–92326 require authorization except for members with a diagnosis of Aphakia, Aniseikonia, Keratoconus, or bandage lenses.
Submit an accurate and complete medical authorization request via MN–ITS (PDF) or on the paper Authorization Form (DHS-4695) (PDF) with the required documentation and fax it to the Authorization Medical Review Agent.
Required documents for authorization include:
Refer to the Billing Section for general billing information. It is the responsibility of the provider to bill with a correct HCPCS code, HCPCS modifiers, ICD diagnosis codes and CPT codes. If the member is enrolled in fee-for-service MHCP, with or without a spenddown, the provider must provide the services and bill MHCP.
Billing for Ocular Photodynamic Therapy (CPT code 67221) is covered only for a valid diagnosis. No separate payment for the intravenous infusion service is allowed. Payment for the infusion is packaged into CPT code 67221.
MN–ITS is a no-cost online DHS web based HIPAA compliant billing, inquiry and communication tool. Computer and internet access is required. Refer to the MN–ITS Interactive 837P User Guide for instructions on billing an individual claim without other insurance or Medicare.
The member may purchase noncovered add-ons and noncovered upgrades. Add-ons are lens treatments that can be added to a pair of covered lenses and frames. Examples are: lens coating, special edge treatments, scratch resistant coating, anti-reflective lens coating, etc. MHCP will pay for the covered frame and lenses, and the member may pay for the cost of the add-on products. The provider must inform the member before providing the add-on that it is not covered by MHCP and that the member is responsible for the payment of the add-on item.
Members may be billed for noncovered upgrades. If a member chooses to purchase upgraded lenses that are not medically necessary (such as noncovered high-index or photochromatic lenses, no-line bifocals) or a non-contract frame, the member is responsible for payment of the entire cost of the lenses or frame. The provider cannot bill the member for the difference between covered lenses and frame and the upgraded lenses and frame. MHCP will not pay for the dispensing fee, repairs or adjustments made to upgraded products or noncovered items.
Providers must bill DHS at their usual and customary charge. MHCP will pay the lower of the submitted charge, the contract rate, or the maximum allowable rate listed on MHCP Fee Schedule, less any MHCP spenddown amount or required payment reduction.
For ophthalmology services, MHCP follows CPT guidelines.
Members with vision and eyeglass coverage from Medicare or private insurance must obtain their eye examination, vision care and eyeglasses through Medicare or their private insurance as primary payers. Note the following:
Once Medicare adjudicates the claim, Medicare crosses the claim over to MHCP with payment and adjustment amounts. If the claim does not cross over to MHCP from Medicare, bill MHCP the same way Medicare was billed and enter the payments and adjustments on the Coordination of Benefits (COB) and Service line level (PDF) tabs on MN–ITS User Manual.
If Medicare does not cover the eyeglasses or vision services, the claim may be submitted directly to MHCP using MN–ITS User Manual.
If private insurance does not provide 100 percent coverage for eyeglasses, eye exams or other vision services, submit the claim to MHCP reporting prior payment and adjustments on the COB tab on MN–ITS User Manual. MHCP will pay up to the allowed payment, less the MHCP copay, spenddown amount or required payment reduction.
MHCP will not pay TPL copays or co-insurance for noncovered items, including add-ons or upgraded lenses or frames. An example of coinsurance is a plan that offers 80/20 coverage and the member is responsible for 20 percent of any outstanding amount.
Services must be provided by an enrolled MHCP provider to be considered for payment.
Follow these guidelines for repairs:
The dispensing provider may bill a dispensing fee when frames or lenses from the contract provider are dispensed. Bill using 92340–92354 as appropriate.
Comprehensive Vision Examination: A complete evaluation of the visual system. The services include patient history, general medical observation, external and ophthalmoscopic examination, gross visual fields, basic sensorimotor examination, biomicroscopy, examination with cycloplegia or mydriasis, and tonometry.
Contract Vendor: The MHCP enrolled optical lab that supplies and assembles eyeglasses for MHCP recipients.
Date of Service: The actual date the service is performed or the supplies are dispensed. The date of service for frames and lenses is the date the eyeglasses were ordered. The date of service for the dispensing fee is the date the eyeglasses are delivered to the recipient.
Deluxe Eyeglass Frame: An eyeglass frame with features that make it more durable than a standard frame, such as spring hinges or memory metal construction.
Dispensing Provider: The MHCP enrolled provider who orders eyeglasses and provides dispensing services to MHCP recipients.
Dispensing Services: The technical services (fitting of spectacles) necessary for the design, fitting, and maintenance of glasses (frames and lenses) as prescribed by an optometrist or ophthalmologist.
Eyeglass or Vision Service: A comprehensive or intermediate vision exam provided by an optometrist or ophthalmologist, or eyeglasses dispensed by an optician, optometrist or ophthalmologist.
Eyeglasses or Spectacles: A pair of lenses mounted in a frame to aid vision, as prescribed by an optometrist or ophthalmologist.
Intermediate Vision Examination: An evaluation of a new or existing specific visual problem complicated with a new diagnosis or management problem not necessarily relating to the primary diagnosis.
Ophthalmologist: A physician who has academic training in ophthalmology beyond the state requirements for licensure and experience in the treatment and diagnosis of the diseases of the eye.
Optician: A supplier of eyeglasses to a patient as prescribed by the patient's optometrist or ophthalmologist.
Optometrist: A person licensed as an optometrist under Minnesota law.
Minnesota Statutes 256B.04 subd.14
Minnesota Statutes 256B.0625 subd. 12
Minnesota Rules 9505.0277
Minnesota Rules 9505.0445
42 CFR 410
42 CFR 411
42 CFR 440.120(d)