Optical Services

Revised: January 2, 2025

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Billing

· Definitions

· Legal References

Overview

Optical services are covered for all eligible Minnesota Health Care Programs (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 are covered for MHCP members.

Contact Classic Optical for frame sample kits, an order form or ordering assistance using any of the following methods:

· Phone: 888-522-2020

· Email: MNClassiccustservice@classicoptical.com

· Fax: 888-522-2022

· Website: classicoptical.com

Providers may dispense noncontract 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, a provider may seek payment from the MHCP member for services only when the provider, before delivering the service, reviews and discusses all other available covered alternatives with the member and obtains a signed release of liability on Advanced Recipient Notice of Noncovered Service/Item (DHS-3640) (PDF).

· Members with third party liability (TPL) that includes coverage of eyeglasses must maximize their benefits through the primary payer first. 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, a provider may seek payment from the MHCP member for services only when the provider, before delivering the service, reviews and discusses all other available covered alternatives with the member and obtains a signed release of liability on Advanced Recipient Notice of Noncovered Service/Item (DHS-3640) (PDF).

Eligible Providers

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

· Ophthalmologist

· Opticians

· Optometrists

Refer to the Optometrist Enrollment Criteria and Forms section of the MHCP Provider Manual for more enrollment information.

Provider Type Home Page Links Review related webpages for the latest news and additions, forms, and quick links. · Information for managed care organizations · Optical Services MHCP Provider Manual section

Eligible Members

Eyeglasses and vision care services are covered for eligible MHCP members who require vision correction. Review the MHCP Benefits at-a-glance section of the MHCP Provider Manual for specific program coverage.

It is the responsibility of the provider to verify eligibility of the member before providing services or ordering eyeglasses. Refer to the Verify Eligibility for MHCP Members section of the MN–ITS User Manual for instructions on how 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 the coverage criteria are met:

· Comprehensive vision examinations, covered once every two years unless there has been a suspected change in vision

· Intermediate vision examinations, covered once every two years unless there has been a suspected change in vision

· One eyeglass fitting or eyeglass dispensing fee within a 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 members aged 21 or older)

· Glass, plastic or polycarbonate lenses for children or adults (MHCP does not require children to have polycarbonate lenses)

· Tinted, ultraviolet (UV), 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 handheld magnifiers (3.7 X 11.0 diopter)

· Double segments (FT25, FT28), plastic or glass

· Fresnel prism or Slab-off prism

· Repairs to frames and lenses

· Contact lenses.

· 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.

· Iris prosthesis (CPT code 66683) for members with a medical diagnosis aniridia. Refer to the Orthotics and Prosthetics section of the MHCP Provider Manual for more information.

Contact Lenses

Contact lenses are covered without authorization if prescribed for aphakia, keratoconus or aniseikonia. Contact lenses prescribed as bandage lenses are also covered without authorization.

Note: All other diagnoses or conditions require authorization for contact lens services and supplies.

For contact lens prescribing and fitting of one eye, use modifier 52.

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.

Contact lenses: S0500, V2500-V2599. One unit = one contact lens. Planned replacement contact lenses may be dispensed as multi-packs. Refer to the following Contact lens codes and dispensing limits table.

Contact lens codes and dispensing limits

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	2 units (1 per eye) per dispensing

Contact Lenses Authorization Requirements

All contact lenses codes S0500 and V2500-V2599 and contact lenses treatment services codes 92070 and 92310–92326 require authorization except for bandage lenses or for members with a diagnosis of aphakia, aniseikonia, keratoconus.

Submit an accurate and complete authorization request to the Medical Review Agent according to the instructions in the Authorization section of the MHCP Provider Manual.

Required documents for authorization include:

· A prescription

· A diagnosis

· Documentation of medical necessity with a detailed explanation of why eyeglasses will not meet the member’s needs.

Providers must contact the Medical Review Agent for any questions or concerns regarding the status of their Authorization request. Refer to the Authorization section of the MHCP Provider Manual for contact information.

Eyeglasses

MHCP does not have authorization requirements for eyeglass benefits. Services not listed are not available through the eyeglasses program.

Eyeglasses and related supplies must meet the following requirements:

· For initial eyeglasses to be medically necessary, there must be a correction of .50 diopters or greater in either sphere or cylinder power in either eye. Diopter is the unit of refracting power of the lens.

· 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 (ANSI) 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 Minnesota Department of Human Services (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. MHCP covers one pair of eyeglasses every two years, unless the member is eligible for replacement eyeglasses as described under the Replacement eyeglasses heading.

All eligible MHCP members may select any approved standard frame, including any that are included in the contract vendor’s online catalog of MHCP-approved frames. 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. Providers should 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, UV, 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. Providers should 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 at least one of the following reasons 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. For purposes of this part, “change in eyeglasses” means a change in prescription.

· 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 eyeglass frames.

· If the member’s eyeglasses are lost, broken, or irreparably damaged, the dispensing provider must obtain a written statement explaining this from the member or their caregiver. An identical pair of eyeglasses will be provided unless the identical frame is not currently available through the contract vendor. Providers must keep a written statement for each occurrence.

Keep documentation of need in the member’s medical record. The reason for replacement must be included in the order.

Repairs
MHCP will pay for repairs to member’s eyeglasses when not covered under warranty. This includes eyeglasses not purchased through MHCP if the eyeglasses are medically necessary and the repair is cost effective.

Eyeglasses purchased through the volume contract may be repaired by the dispensing provider or sent to the contract vendor for repairs.

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 or polaroid filters, and other lenses or devices.

· Visual therapy for amblyopia is limited to children under 10 years old. The member must be referred to an appropriate professional (for example, neurologist or ophthalmologist) for further evaluation if improvement is not noted after four sessions.

The physician monitoring the member’s progress may bill for a limited examination in addition to the orthoptic or pleoptic training. Document in the medical record the physician saw the member 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:

· Cosmetic services: (for example, contact lenses prescribed for reasons other than aphakia, keratoconus, aniseikonia, marked acuity improvement over correction with eyeglasses, or therapeutic application; or replacement of lenses or frames due to member’s personal preference for a change of style or color)

· Dispensing services related to noncovered services

· Fashion tints or polarized lenses unless medically necessary

· Protective coating for plastic lenses

· Edge and anti-reflective coating of lenses

· Industrial or sport eyeglasses unless they are the member’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 the provider’s error in prescribing, frame selection or measurement. The provider making the error is responsible for bearing the cost of correcting the error

· Services or materials that are considered experimental or not clinically proven by prevailing community standards or customary practice.

· Repair of eyeglasses during the warranty period if the repair is covered by warranty.

· Purchase of eyeglasses or lenses not covered by a contract obtained through the competitive bidding process under Minnesota Rules, part 9505.0200.

· Backup eyeglasses or split prescription into two pairs of eyeglasses

· Reading glasses that do not require a prescription

· Saline or other solutions for the care of contact lenses

· Vision therapy for learning disabilities, including dyslexia.

Billing

Refer to the Billing Policy Overview section of the MHCP Provider Manual for general billing information.

Submit 837P Professional Claim through MN–ITS.

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

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 noncontract 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

MHCP follows CPT guidelines for ophthalmology services.

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.

After 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.

Submit claim for services that are not covered by Medicare directly to MHCP. You do not need a denial from Medicare.

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 Coordination of Benefits (COB) in MN–ITS. 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 coinsurance 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.

Providers must be enrolled in MHCP to have their services considered for payment by DHS.

Repairs

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.

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.

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 members.

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 member.

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 members.

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 subdivision 14 (Competitive bidding)
Minnesota Statutes, 256B.0625 subdivision 12 (Eyeglasses, dentures, and prosthetic devices)
Minnesota Rules, 9505.0277 (Eyeglass services)
Minnesota Rules, 9505.0445 (Payment rates)
Code of Federal Regulations, title 42, section 410
Code of Federal Regulations, title 42, section 411
Code of Federal Regulations, title 42, section 440.120(d)