Vision Examinations & Optical Hardware Coverage & Billing Guidelines Contents General Policy... 2 Indications and Limits of Coverage... 2 Vision Examinations... 2 Diagnostic Testing... 2 Eyeglasses... 3 Contact Lenses... 5 Eye Prostheses... 5 Low Vision Aids... 5 Replacement of Glasses... 6 Family Accessories Program... 6 Billing Procedures... 6 Example #1A Child (member under 21) gets standard frames and polycarbonate lenses:... 7 Example #1B Child (member under 21) gets deluxe frames and polycarbonate lenses:... 7 Example #2A Adult (member over 21) gets Standard Frame and Polycarbonate Lenses... 7 Example #2B Adult (Member over 21) gets Standard Frames and Progressive Lenses... 8 Example #2C Adult (Member over 21) gets Deluxe Frames and Progressive Lenses... 8 Example #3 A member (child or adult) requiring a lenticular lenses.... 8 Example #4 A member (child or adult) wants deluxe frames.... 9 Example #5 A member with the diagnosis of aphakia needs contact lenses.... 9 Example #6 A member with no diagnosis of aphakia wants contact lenses.... 9 1
General Policy Family covers vision services for its members. Benefits vary based upon age and the benefit category of the member and are facilitated by Family participating vision care providers. Indications and Limits of Coverage For any item to be covered it must be: 1. Medically necessary. 2. Covered under the member s defined benefit category. 3. Not specifically excluded from Medical Assistance Coverage. 4. Approved with Prior Authorization from Family when appropriate. Vision Examinations Vision Examinations are covered for all members. Members under 21 receive two examinations per year. Members over 21 receive one examination per year. Providers should bill the applicable vision exam code that is on the Medical Assistance fee schedule. Examples of these codes are: Vision Exam Description Codes 92004 Ophthalmological services: Medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits. 92014 Ophthalmological services: Medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, established patient, one or more visits. Providers Places of Service Types 01 Only place of service 22 08 Only place of service 49 18 11, 12, 21, 31 or 32 31 11, 12, 21, 31, 32 or 54 01 Only place of service 22 08 Only place of service 49 18 11, 12, 21, 31 or 32 31 11, 12, 21, 31, 32 or 54 Diagnostic Testing Only diagnostic testing that is medically necessary is covered by Family. Diagnostic testing codes currently covered by the Medical Assistance Fee Schedule, when medically necessary are: 92015 92020 92082 92083 92140 92235 92270 92275 92283 92284 92285 92286 92542 92544 92546 92547 2
Eyeglasses Family covers glasses or contact lenses for members. Members under the age of 21 can receive up to two (2) full pairs of standard eyeglasses (2 frames and 4 lenses) per benefit year. Members over the age of 21 can receive one (1) full pair of eyeglasses (1 frame and 2 lenses per year). The benefit year for eyeglasses begins on March 1 st and ends on February 28 th regardless of the date upon which the member gained eligibility or became a member of Family. Members under the age of 21 are not required to wait to utilize the benefit for a second full pair of eyeglasses. However, member benefits will be configured per day and therefore, a member will not be able to receive multiple pairs of eyeglasses in the same day. All eyeglasses prescribed to Family members will come with a 1 year warranty provided by the vision provider. Applicable to the warranty, providers are responsible to replace broken frames or lenses during the one year period. Scratched lenses will not be covered by the warranty. Providers will also be responsible for making simple eyeglass repairs for Family members at no cost. Lost eyeglasses will be replaced by utilizing any remaining benefits the member has for the current benefit year. Family will cover all frames and lenses included on the Medical Assistance fee schedule, which can be located at: http://www.dpw.state.pa.us/publications/forproviders/schedules/mafeeschedules/outpatientfeesched ule/index.htm *Note that this fee schedule is subject to change at the discretion of the Pennsylvania Department of Public Welfare. Standard eyeglasses include standard frames and standard lenses. The standard lenses can be single vision, bifocal, trifocal or spherocylinder. Standard eyeglass codes covered by the Medical Assistance fee schedule are as follows: Frames MA Reimbursement Amount V2020 - Basic Frames $7.00 Glass Lenses V2100 single $15.00 V2101 single $17.50 V2102 single $20.00 V2121 - Lenticular, single $50.76 V2200 bifocal $20.00 V2201 bifocal $22.50 V2202 bifocal $25.00 V2221 - Lenticular, bifocal $62.50 V2321 - Lenticular, trifocal $91.26 *Please note that the rates listed are the rates provided by the Department of Public Welfare. Your provider contract with Family will provide more details about your specific reimbursement rates. 3
For spherocylinder lenses, providers should bill to the highest level of specificity. Spherocylinder lenses are considered a standard benefit. When billing for lenses, Family providers should not use the 50 billing modifier. The 50 modifier will cause claims to be denied. Instead, providers should use the RT and LT modifiers to have claims process correctly. Additionally, providers may submit claims for lenses with a unit of two without applying the RT and LT modifiers. For Family members, providers should not submit claims using S-codes for the exam and refraction, such as S0620 or S0621. Since these codes are not on the Medical Assistance fee schedule, submitting these codes will cause the claim to deny as P2. As an alternative to standard eyeglasses, Family will cover towards customized eyeglasses as indicated in the Billing Procedures below. Members under the age of 21 may use this allowance twice per benefit year. Members over the age of 21 may use this allowance once per benefit year. Codes that are considered non-standard are as follows: V2025 V2115 V2116 V2117 V2118 V2199 V2215 V2216 V2217 V2218 V2219 V2220 V2299 V2300 V2301 V2302 V2315 V2316 V2317 V2318 V2319 V2320 V2399 V2410 V2430 V2499 V2702 V2718 V2730 V2750 V2755 V2760 V2761 V2762 V2780 Polycarbonate lenses (V2784) are covered for individuals under the age of 21. For individuals over the age of 21, polycarbonate lenses are non-standard and would apply towards the allowance. Polycarbonate Lenses MA Reimbursement Amount V2784 Polycarbonate Lens $29.73 Family will not cover the following codes, which include items such as tinting, transition, and/or progressive lenses. Members may not use the non-standard allowance toward these items. Noncovered codes are: V2740 V2741 V2742 V2743 V2744 V2756 V2781 V2785 4
Contact Lenses Family will cover the full cost of contact lenses with a prior authorization in some instances. PMMA or gas permeable contact lenses that are medically necessary will be covered with prior authorization. Hydrophilic spherical contact lenses (soft contact lenses) for aphakia are also covered with a prior authorization. In the case of a member who has cataract surgery, replacement lenses, overcorrection lenses or implanted lenses will be covered with prior authorization. Covered contact lens codes are: Contacts MA Reimbursement Amount V2500 - PMMA, per lens $50.00 V2502 - PMMA, bifocal, per lens $100.00 V2510 - gas permeable, per lens.00 V2512 - bifocal, per lens $150.00 V2520 - hydrophilic, aphakia $90.00 V2521 - hydrophilic, aphakia $90.00 V2522 - hydrophilic, aphakia $90.00 V2523 - hydrophilic, aphakia $90.00 V2715 - Prism, per lens $8.88 Disposable Hydrophilic (soft) contact lenses without a prior authorization are not covered absent the diagnosis of aphakia, but may be purchased using the allowance in lieu of using it on eyeglasses. Examples of contact lens codes providers may use for this scenario are: S0500 S0512 S0514 Contact lens fittings are only covered for medically necessary lenses (i.e. for lenses prescribed for aphakia or after cataract surgery). Fittings for lenses that are not medically necessary, such as those for disposable soft contacts for cosmetic purposes are not covered. Eye Prostheses Eye prostheses are covered for all members when medically necessary. This benefit is limited to 1 every 2 years. The covered code for eye prostheses is V2623. Low Vision Aids Low vision aids (hand held) are covered for all members when medically necessary. This benefit is limited to 1 every 2 years. The covered code for a low vision aid is V2600. 5
Replacement of Glasses All eyeglasses prescribed to Family members will come with a 1 year warranty provided by the vision provider. Applicable to the warranty, providers are responsible to replace broken frames or lenses during the one year period. Necessary replacement of glasses if they are broken, lost, or if a prescription changes can be accommodated through a benefit limit exception if the member has used all of their benefits during the applicable benefit year. Family Accessories Program Family members may also use the Accessories Program to access discounts on eye exams, contact lenses and contact lens fittings and eyeglasses. Many major retailers such as LensCrafters and Target Optical provide a discount through the Accessories Program. Providers who participate in this program are typically non-par providers. Any service provided through the Accessories Program would be provided at a discount to the member; however, because the providers are non-participating, Family would not be billed. The member would have full responsibility for all costs above and beyond the applicable discount. Billing Procedures Family providers should always bill with a complete diagnosis code, a correct place of service and appropriate modifiers where applicable. Vision hardware (eyeglasses or contacts) must be billed upon pickup by the member. Family will use a line item billing system. Please see the example billing scenarios on the following pages. 6
Example #1A Child (member under 21) gets standard frames and polycarbonate lenses: V2020 Standard 30.00 7.00 23.00 0.00 0.00 7.00 V2100 X 2 40.00 30.00 10.00 0.00 0.00 30.00 Standard V2784 X 2 80.00 59.46 20.54 0.00 0.00 59.46 Polycarbonate Total 150.00 96.46 43.64 0.00 0.00 96.46 Because the member is under 21, Family is responsible for the entire claim, and the member has no financial responsibility. The provider is reimbursed the total amount based off the MA Fee Schedule. Example #1B Child (member under 21) gets deluxe frames and polycarbonate lenses: V2100 X 2 40.00 30.00 10.00 0.00 30.00 30.00 Standard V2784 X 2 80.00 59.46 20.54 0.00 59.46 59.46 Polycarbonate V2025 Deluxe 110.00 0.00 0.00 110.00 0.00 0.00 Frame Total 230.00 89.46 30.54 110.00 89.46 89.46 Because the member upgraded to deluxe frame, the allowance is applied. In this example, because polycarbonate lenses are required for a member under 21, it will reimburse the MA Fee Schedule amount, or $59.46. The provider is entitled to a total payment of $199.46. Family will reimburse the provider $89.46 and the member is responsible for the balance of $110.00. Example #2A Adult (member over 21) gets Standard Frame and Polycarbonate Lenses V2020 Standard 30.00 7.00 23.00 0.00 7.00 7.00 V2100 X 2 40.00 30.00 10.00 0.00 30.00 30.00 Standard V2784 X 2 80.00 59.46 20.54 21.46 38.00 38.00 Polycarbonate Total 150.00 96.46 43.64 21.46 75.00 75.00 The polycarbonate lenses are an upgrade for adults, therefore, Family will pay the provider and the provider should bill the remaining balance of $21.46 to the member directly. 7
Example #2B Adult (Member over 21) gets Standard Frames and Progressive Lenses V2020 Standard 30.00 7.00 23.00 0.00 0.00 7.00 V2200 X 2 Bifocal 85.00 40.00 45.00 0.00 0.00 40.00 Lens V2781 X 2 180.00 0.00 0.00 180.00 0.00 0.00 Progressive Lens Total 210.00 47.00 68.00 180.00 0.00 47.00 In this case, progressive lenses are not a covered benefit and cannot be applied to the allowance. The Member is only covered for the standard frames and bifocal lenses. The member would be responsible for the total cost of the progressive lenses. Example #2C Adult (Member over 21) gets Deluxe Frames and Progressive Lenses V2025 Deluxe 100.00 0.00 0.00 65.00 35.00 35.00 Frame V2200 X 2 Bifocal 85.00 40.00 45.00 0.00 40.00 40.00 Lens V2781 X 2 180.00 0.00 0.00 180.00 0.00 0.00 Progressive Lens Total 365.00 40.00 45.00 245.00 75.00 75.00 In this case, progressive lenses are not a covered benefit and cannot be applied to the allowance. Family will reimburse the provider and the member is responsible for the balance. Example #3 A member (child or adult) requiring a lenticular lenses. V2020 Standard 30.00 7.00 23.00 0.00 0.00 7.00 V2121 X 2 200.00 101.52 98.48 0.00 0.00 101.52 Lenticular Lens Total 230.00 108.52 121.48 0.00 0.00 108.52 In this case, because lenticular lenses are a fully covered benefit and not an upgrade, Family will reimburse the provider for the entire balance and the member will have no liability. 8
Example #4 A member (child or adult) wants deluxe frames. V2025 Deluxe 100.00 0.00 0.00 55.00 45.00 45.00 Frames V2100 X 2 40.00 30.00 10.00 0.00 30.00 30.00 Standard Lens Total 140.00 30.00 10.00 55.00 75.00 75.00 In this case, the provider should bill Family for the deluxe frames at the retail rate because there is no MA Fee Schedule value for a deluxe frame as this is traditionally a non-covered service. Family will pay the provider toward the cost of this pair of glasses and the remaining $55 is the responsibility of the member. Example #5 A member with the diagnosis of aphakia needs contact lenses. V2521 X 2 250.00 180.00 70.00 0.00 0.00 180.00 Hydrophilic lenses Total 250.00 180.00 70.00 0.00 0.00 180.00 Family will reimburse the provider $180 because the contact lenses are medically necessary due to the member s condition and are a standard benefit on the MA fee schedule. Example #6 A member with no diagnosis of aphakia wants contact lenses. S0500 Contacts 100.00 0.00 0.00 25.00 75.00 75.00 / box Total 100.00 0.00 0.00 25.00 75.00 75.00 Family will reimburse the provider for the contact lenses. The provider should bill the contacts at the retail rate as there is no rate on the MA fee schedule. The member will be responsible for the remaining $25. 9