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Optical Services

Revised: 10-03-2018

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Noncovered Services
  • Authorization Requirements
  • Billing
  • Definitions
  • Legal References
  • Overview

    Optical services are covered for all eligible MHCP members.

    Volume Purchase Contract for Eyeglasses

    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:

  • • Phone: 888-522-2020
  • • Email:
  • • Fax: 888-522-2022
  • • Website:
  • Providers may dispense non-contract eyeglasses only if one of the following exceptions applies:

  • • Members who are dually eligible for Medicare and MHCP may select noncontract eyeglasses if Medicare is reasonably expected to pay for the eyeglasses. Members who want MHCP to pay for eyeglasses that Medicare denies must select contract eyeglasses. If the member has selected noncontract eyeglasses and Medicare denies the claim, the dispensing provider may bill the member for the eyeglasses if the member was clearly notified that MHCP would not cover the noncontract eyeglasses if Medicare denies the claim.
  • • Members with third party liability that includes coverage of eyeglasses must maximize their benefits through the primary payer. MHCP will pay coinsurance and deductible amounts up to the MHCP allowable rate on noncontract eyeglasses that are paid for by the primary payer. If the member has selected noncontract eyeglasses and the primary payer denies the claim, the dispensing provider may bill the recipient for the eyeglasses if the member was clearly notified that MHCP would not cover the noncontract eyeglasses if the primary payer denies the claim.
  • Eligible Providers

    The following MHCP enrolled providers may dispense eyeglasses and perform vision services within their scope of practice:

  • • Ophthalmologist
  • • Opticians
  • • Optometrists
  • Refer to Provider Enrollment for additional detailed enrollment information.

    Provider Type Home Page Links
    Review related webpages for the latest news and additions, forms, and quick links.

    Eligible Members

    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.

    Covered Services

    Keep documentation of medical necessity in the member’s medical records. The following services are covered when medically necessary and coverage criteria are met:

  • • Comprehensive vision examinations
  • • Intermediate vision examinations
  • • One dispensing fee within a thirty-day period
  • • Eyeglass frames
  • • Deluxe eyeglass frames for adults with cognitive disabilities, seizure conditions or for children (a specific diagnosis is required for deluxe frames for members aged 21 or older)
  • • Glass, plastic or polycarbonate lenses for children or adults (MHCP does not require children to have polycarbonate lenses)
  • • Tinted, U-V, polarized or photochromatic lenses for certain childhood, visual, or seizure conditions when standard lenses may pose a risk (a specific diagnosis is required)
  • • High index lenses when the correction in either eye is plus or minus 6.00 diopters or greater
  • • Aspherical hand held magnifiers (3.7 X 11.0 diopter)
  • • Double segs (FT25, FT28), plastic or glass
  • • Fresnel prism, Slab off prism
  • • Repairs to frames and lenses
  • • Contact lenses
  • Contact Lenses

    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

    HCPCS code


    Disposable contact lens


    1-month supply, up to 30 per eye per dispensing

    PMMA, gas permeable, gas impermeable contact lens

    V2500-V2513, V2530-V2599

    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:

  • • Lenses covered by MHCP must be first-quality impact-resistant glass, plastic or polycarbonate single vision, bifocal or trifocal lenses
  • • Lenses must conform to the American National Standards Institute Recommendation for Prescription Ophthalmic Lenses, ANSI's most current standards, and the FDA requirements for impact resistance
  • • All lenses must be finished (hardened and edged) and assembled in the frame
  • • A new eyeglass case must be included with each pair of eyeglasses
  • • The contract vendor must replace or repair eyeglasses the member finds to be unsatisfactory due to defective workmanship or materials without cost to the member or MHCP
  • • Errors made in prescribing or dispensing are the responsibility of the prescribing or dispensing provider. The contract provider will notify DHS when replacement eyeglasses are ordered due to errors in prescribing or dispensing. DHS may instruct the prescribing or dispensing provider to make payment to the contract provider.
  • Eyeglass Frames
    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.

    Eyeglass Lenses
    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.

    Replacement eyeglasses
    Vision providers may dispense a new pair of eyeglasses when one or more of the following reasons for medical necessity are met:

  • • There is a change in correction of 0.5 diopters or greater in either sphere or cylinder power in either eye
  • • There is a shift in axis of greater than 10 degrees in either eye
  • • A comprehensive or intermediate vision examination shows that a change in eyeglasses is medically necessary
  • • A change in the member’s head size warrants a new pair of eyeglasses
  • • The member has had an allergic reaction to the previous pair of eyeglasses
  • • The original pair is lost, broken, or irreparably damaged; the dispensing provider must obtain a written statement explaining this from the member (or the member’s caretaker), and must include the reason for replacement on the eyeglass order. If the original pair is lost, broken or damaged beyond repair, the eyeglasses will be replaced with an identical pair of eyeglasses, unless the identical frame is not available through the contract vendor. If a previous pair was ordered through the contract vendor, the contract vendor will notify the dispensing vendor that the eyeglasses will be replaced with an identical pair.
  • 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.

    Vision Therapy or Orthoptics and Pleoptics

    Coverage Criteria
    Refer to the following criteria for coverage:

  • • Diagnosis and treatment of amblyopia, sensory or motor strabismus, and accommodative disorders causing subjective visual complaints which are not relieved by wearing prescription eyewear
  • • Home visual therapy is to be used, including home treatment with patching, lens fogging, red/green/polaroid filters, and other lenses or devices
  • • Visual therapy for amblyopia is limited to children under 10 years old. If improvement is not noted after four sessions, the member must be referred to an appropriate professional (for example, neurologist or ophthalmologist) for further evaluation
  • 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.

    Noncovered Services

    The following services are not covered:

  • • Replacement of lenses or frames to change the style or color
  • • Cosmetic services
  • • Tints or polarized lenses for fashion purposes
  • • Protective coating for plastic lenses
  • • Edge and anti-reflective coating of lenses
  • • Industrial, sport eyeglasses or glasses for computer screen usage, unless they are the recipient’s only pair and are necessary for vision correction
  • • Invisible bifocals or progressive bifocals
  • • Contact lenses which require authorization when authorization was not obtained
  • • Replacement of lenses or frames due to provider error in prescribing, frame selection, or measurement
  • • Eyeglasses or lenses for occupational or educational needs, unless it is the recipient’s only pair and it is necessary for vision correction
  • • Services or materials that are considered experimental or not clinically proven by prevailing community standards or customary practice
  • • Backup eyeglasses or split prescription into two pairs of eyeglasses
  • • Reading glasses without a prescription
  • • Saline or other solutions for the care of contact lenses
  • • Vision therapy for learning disabilities, including dyslexia
  • Authorization Requirements

    Contact Lenses

    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:

  • • A prescription
  • • A diagnosis
  • • Documentation of medical necessity with a detailed explanation of why eyeglasses will not meet the members needs
  • Billing

    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.

    Billing the Member for Add-ons and Upgrades

    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.

    Maximum Allowable Rates

    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.

    New vs. Established Patient

    For ophthalmology services, MHCP follows CPT guidelines.

    Members with Medicare or Private Health Insurance Coverage

    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:

  • Medicare does not cover eyeglasses except for aphakia or following cataract surgery
  • Always verify service or program coverage with Medicare before submitting a claim
  • Providers must submit the claims to Medicare for Medicare-covered services
  • • MHCP will not pay Medicare-covered services without Medicare adjudication
  • 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 contract vendor may bill replacement frames or lenses using the appropriate frame or lens code with modifier RA.
  • • Bill repairs to eyeglasses using 92370 or 92371
  • • If the cost of the repair will exceed the allowable cost of new frames and lenses through MHCP, new frames and lenses may be ordered. The dispensing provider should document how the eyeglasses were broken, what repairs were needed, and the estimated cost of the repair. Bill using the appropriate frame and lens code with the RA modifier
  • Dispensing fees

    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.

    Legal References

    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)

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