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Department of Human Services Department of Human Services  
 
Eyeglass and Vision Care Services

Revised: 09-19-2013


Overview
Eyeglasses and vision care services are covered for all eligible MHCP recipients.

Volume Purchase Contract for Eyeglasses
MHCP purchases eyeglasses (frames and lenses) via a volume purchase contract (PDF). Dispensing providers must obtain an eyeglass frame sample set from the Contract Vendor. Only frames and lenses from the contract vendor will be covered for MHCP recipients. Providers may dispense non-contract eyeglasses only if one of the following exceptions applies:

• Recipients who are dually eligible for Medicare and MHCP may select non-contract eyeglasses if Medicare is reasonably expected to pay for the eyeglasses. Recipients who want MHCP to pay for eyeglasses that are denied by Medicare must select contract eyeglasses. If the recipient has selected non-contract eyeglasses and the claim is denied by Medicare, the dispensing provider may bill the recipient for the eyeglasses if the recipient was clearly notified that MHCP would not cover the non-contract eyeglasses if Medicare denies the claim.
• Recipients with Third Party Liability that includes coverage of eyeglasses must maximize their benefits through the primary payer. MHCP will pay co-insurance and deductible amounts up to the MHCP allowable rate on non-contract eyeglasses that are paid for by the primary payer. If the recipient has selected non-contract eyeglasses and the claim is denied by the primary payer, the dispensing provider may bill the recipient for the eyeglasses if the recipient was clearly notified that MHCP would not cover the non-contract eyeglasses if the primary payer denies the claim.

Volume Purchase Advisory Committee
DHS and Department of Administration representatives meet with volume purchase vendors as needed to discuss contract implementation and issues. Concerns about the volume purchase contracts should be directed, in writing, to:

Minnesota Department of Administration
Materials Management Division
112 Administration Building
50 Sherburne Avenue
St. Paul, MN 55155


Eligible Providers
The following MHCP enrolled provider may dispense eyeglass 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 Web pages for the latest news and additions, forms, and quick links.


Eligible Recipients
Eyeglasses and vision care services are covered for eligible MHCP recipients 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 recipient and determine when the last pair of MHCP eyeglasses were dispensed before providing services or ordering eyeglasses. Use the MN–ITS Interactive Eligibility Request (PDF) or 270 transaction to determine eligibility and determine when the recipient’s last pair of MHCP eyeglasses was dispensed.


Covered Services
Documentation of medical necessity must be kept in the recipients’ medical records. The following services are covered service when medically necessary and coverage criteria are met:

• Comprehensive vision examinations
• Intermediate vision examinations
• One dispensing fee within a thirty (30) 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 recipients age 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/conditions require authorization for contact lens services and supplies.

Bandage / Therapeutic Lenses:92071 and 92072. Includes the supply of the contact lens, Claims for contact lenses for the same date of service will be denied. When performed bilaterally, bill two units on one line with modifier 50.Must include an appropriate diagnosis.

Bilateral prescribing / fitting of contact lenses except for aphakia codes: 92310 and 92314. Use modifier 52 when prescribing and fitting one eye,

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 Limit
Disposable contact lens S0500 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 V2520-V2523 1 multi-pack per eye, up to 12 units per dispensing

Eyeglasses

• 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
• Eyeglasses found by the recipient to be unsatisfactory due to defective workmanship/materials must be replaced or repaired by the contract vendor without cost to the recipient or MHCP
• Errors made in prescribing or dispensing are the responsibility of the prescribing and/or dispensing provider. The contract provider will notify DHS when replacement eyeglasses are ordered due to errors in prescribing and/or dispensing. DHS may instruct the prescribing/dispensing provider to make payment to the contract provider.

Eyeglass Frames
MHCP has approved approximately 80 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 35 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 recipients may select any approved standard frame. Recipients under age 21 and adult recipients with cognitive disabilities or seizure disorders may select approved deluxe frames. When a deluxe frame is ordered for a recipient age 21 or older, the dispensing provider must include an appropriate diagnosis code on the order. The contract vendor must include an appropriate diagnosis on the claim. Questions about inclusion of a specific diagnosis should be directed to MHCP.

Recipients may select approved frames without lenses when purchasing non-covered lenses. The dispensing provider must be able to mount the non-covered lenses in the frames. The dispensing provider must clearly inform the recipient that the frames will be covered when ordered from the contract vendor, but that all costs associated with the non-covered lenses and mounting of the lenses will be the recipient’s responsibility.

Eyeglass Lenses
Recipients with medical conditions that may be affected or aggravated by bright or changing light conditions may require tinted, U-V, polarized or photochromatic lenses. When photochromatic, tinted or polarized 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. Questions about inclusion of a specific diagnosis should be directed to MHCP.

Recipients may request covered lenses for recipient-owned frames. The dispensing provider must clearly inform the recipient that if the contract vendor determines that mounting the lenses in the recipient-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 recipient. If the recipient is purchasing non-approved frames for use with covered lenses, the dispensing provider must clearly inform the recipient of any applicable return policies. The dispensing provider is not required to accept recipient-owned frames for transmittal to the contract vendor if their normal business practice would not include placing lenses in those frames.

Receiving Eyeglasses More Frequently Than Every Two Years
It is expected that with reasonable care eyeglasses should not need to be replaced due to loss or damage more than once in a two year dispensing period. However, vision providers may dispense a new pair of eyeglasses, even though two years have not passed since a recipient's last pair was dispensed when one or more of the following reasons for medical necessity criteria for 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
• There is a change in the recipient's head size which warrants a new pair of eyeglasses
• The recipient 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 recipient (or the recipient’s caretaker), and send a copy of this documentation to the contract vendor with the 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.

Documentation of medical necessity for the above situations must be kept in the recipient’s medical record. The reason for the replacement must be included on the order when new eyeglasses are ordered from the contract vendor.

Repairs
MHCP will pay for repairs to recipient 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/Orthoptics and Pleoptics
All vision therapy requires authorization.

Coverage Criteria

• 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/devices
• Visual therapy for amblyopia is limited to children under age 10. If improvement is not noted after four sessions, the recipient must be referred to an appropriate professional (e.g., neurologist or ophthalmologist) for further evaluation

The physician monitoring progress may bill for a limited examination in addition to the orthoptic/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.


Non-Covered Services
• 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
MHCP does not have prior authorization requirements for eyeglass benefits. Services not listed are not available through the eyeglasses vision program.

Contact Lenses
All contact lenses codes S0500 and V2500-V2599 and Contact Lenses Treatment Services codes 92070 and 92310 - 92326 require authorization except for recipient 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) with the required documentation and fax it to the Authorization Medical Review Agent.

Required documents for authorization includes:

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

Visual Therapy/Orthoptics/Pleoptics (92065)
All vision therapy requires authorization. Fax an accurate and complete Medical Authorization Request via MN–ITS or on the paper Authorization Form (DHS-4695), a completed Vision Therapy Form (DHS-4879) and all required documentation to the Authorization Medical Review Agent.


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-9 codes and CPT codes. If the recipient 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 ICD-9-CM 362.52. No separate payment for the intravenous infusion service is allowed. Payment for the infusion is packaged into CPT code 67221.

MN–ITS
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 (PDF) for instructions on billing an individual claim without other insurance or Medicare.

Billing the Recipient for Add-ons and Upgrades
The recipient may purchase non-covered add-ons and non-covered 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/or lenses, and recipients may pay for the cost of the add-on products. The provider must inform the recipient before providing the add-on that it is not covered by MHCP and that the recipient is responsible for the payment of the add-on item.

Recipients may be billed for non-covered upgrades. If a recipient chooses to purchase upgraded lenses that are not medically necessary (such as non-covered high-index or photochromatic lenses, no-line bifocals) or a non-contract frame, the recipient is responsible for payment of the entire cost of the lenses or frame. The provider cannot bill the recipient for the difference between covered lenses and/or frame and the upgraded lenses and/or frame. MHCP will not pay for the dispensing fee, repairs or adjustments made to upgraded products or non-covered 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.

Recipients with Medicare or Private Health Insurance Coverage
Recipients 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.

• Medicare does not cover eyeglasses except for aphakia or following cataract surgery
• Always verify service/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 crossover 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 (PDF).

If eyeglasses or vision services are not covered by Medicare, the claim may be submitted to MHCP using MN–ITS (PDF).

If private insurance does not provide 100% 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 (PDF). MHCP will pay up to the allowed payment, less the MHCP copay, spenddown amount or required payment reduction.

MHCP will not pay TPL co-pays or co-insurance for non-covered items, including add-ons or upgraded lenses/frames. An example of co-insurance is a plan that offers 80/20 coverage and the recipient is responsible for 20% of any outstanding amount.

Services must be provided by an enrolled MHCP provider to be considered for payment.

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 92370/92371
• 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 and/or lenses from the contract provider are dispensed. Bill using 92340-92354 as appropriate.


Definitions
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/or lenses) as prescribed by an optometrist or ophthalmologist.

Eyeglass/Vision Service: A comprehensive or intermediate vision exam provided by an optometrist or ophthalmologist and/or eyeglasses dispensed by an optician, optometrist or ophthalmologist.

Eyeglasses/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 Statute 256B.04 subd.14
Minnesota Statute 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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