Vision Services September 2019

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Overview

• Provider Enrollment Requirements

• Recordkeeping Requirements

• Member Eligibility

• Covered Services

• Billing

• Additional Resources

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Provider Enrollment

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Vision Provider Enrollment Requirements

Providers must be enrolled in Alaska Medicaid to bill for reimbursement of covered health

care services to eligible Alaska Medicaid members.

• Eligible vision providers include:

– Ophthalmologists

– Opticians

– Optometrists

• In addition to appropriate licenses, all vision providers must have an NPI to enroll

• Providers that are associated with groups must first enroll as individuals and then affiliate

with an Alaska Medicaid enrolled group

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Vision Provider Enrollment Requirements

Ophthalmologist

• Must meet all physician enrollment requirements, including an active license from the

Alaska Division of Occupational Licensing to practice medicine or osteopathy, and enroll

with Alaska Medicaid as a physician

• Licensed physicians must also be certified by the American Academy of Ophthalmology to

enroll with a specialization in ophthalmology

Opticians

• Must have an active license from the Alaska Department of Commerce, Community, and

Economic Development to practice as a certified dispensing optician to enroll in Alaska

Medicaid

Optometrists

• Must have an active occupational license from the Board of Examiners in Optometry to

practice optometry

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Enrollment Fee

• Enrolling providers who will be billing for their services must pay an enrollment fee to AK

Medicaid as part of their enrollment process, in accordance with 42 CFR 455.460

• The fee for 2018 is $569 – the fee is adjusted annually

• A check or cashier’s check for the correct amount, payable to the Alaska Department of

Health and Social Services, must be submitted with the enrollment application

• Providers who have already paid an enrollment fee to Medicare or another state’s Medicaid

or CHIP program, you do not need to pay the enrollment fee to AK Medicaid, but will need to

provide evidence of having paid the fee to the other agency

• Providers who will be rendering providers only do not need to pay the enrollment fee

• For more information on the enrollment fee, see the Provider Enrollment Fee FAQ

Update Provider Information Form

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http://manuals.medicaidalaska.com/docs/dnld/Form_Update_Provider_Information.pdf

All forms with original signatures should be

mailed to:

P.O. Box 240808

Anchorage, AK 99524-0808

Providers may also choose to deliver them to

Conduent located at:

1835 S. Bragaw St.

Anchorage, AK 99508

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Recordkeeping

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Recordkeeping

• Recordkeeping requirements are documented in the Individual and Group/Facility Provider

Agreements and Tax Certifications

• Providers must comply with general and provider-specific recordkeeping requirements

• Providers must maintain complete and accurate clinical, financial, and other relevant

records to support the care and services for which they bill Alaska Medical Assistance for a

minimum of 7 years from the date of service

• Providers are subject to audits, reviews and investigations

Providers are responsible for ensuring that their staff, billing agents, and any other entities

responsible for any aspect of records maintenance uphold these requirements.

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Recordkeeping Regulations

• Alaska Administrative Code rules for the Medicaid program are found in 7 AAC 105-7 AAC

160

• Go to http://www.legis.state.ak.us/basis/aac.asp

– Select Index (ToC) > 7 Health and Social Services > Part 8. Medicaid coverage and

Payment

• 7 AAC 105.230 Requirements for Provider Records

• 7 AAC 105.240 Request for Records

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Member Eligibility

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Member Eligibility

Always verify member eligibility by using one of the following options:

• Request to see the member's eligibility coupon or card that shows the current month of

eligibility; photocopy for your records

• Call Automated Voice Response System (AVR):

– 855.329.8986 (toll-free)

• Verify via Alaska Medicaid Health Enterprise website

– http://medicaidalaska.com

• Fax complete Member Eligibility Inquiry Form - Vision

– 907.644.8126

• Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction

• Call Provider Inquiry

– 907.644.6800, option 1 or 800.770.5650, option 1, 1 (toll-free)

NOTE: Member eligibility can be checked by any of these methods; service limits can

be verified only by calling Provider Inquiry or faxing in the Vision Eligibility fax form

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Member Eligibility Code Category

11 Pregnant Woman (Alaska Health Baby Program)

20 No Other Eligibility Codes Apply

24 Institutional LTC Medicaid

30/31 Waiver for adults with physical and developmental disabilities

34 APDD, Waiver Adult Public Assistance (APA)/Qualified Medicare Beneficiary (QMB)

40/41 Older or disabled adult with waiver and Medicaid

44 ALI, Waiver APA/QMB

50 Under 21

51 Juvenile Court Ordered Custody of Health & Social Services

52 Transitional Medical Assistance

54 Disabled/Supplemental Security Income (SSI) Child

69 APA/QMB – Dual Eligibility

70/71 Intellectual and Developmental Disabilities (IDD), Waiver

74 IDD, Waiver APA/QMB

80/81 Medically Complex Children - Waiver

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Vision Services Eligibility

Vision services are not covered for the following eligibility types:

Code Category

15 Pregnancy of incapacity determination exam

25 Disability/blindness exam

53 Emergency Alien Medicaid

62 QDWI

66 QDWI - Eligible for payment of Medicare Part A monthly premium only

67 QMB

68 SLMB – Eligible for payment of Medicare Part B monthly premiums only

78 SLMB Plus – Eligible for payment of Medicare Part B monthly premiums

only

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Member Eligibility Cards & Coupons

1. Member Name 4. Eligibility Code

2. Member ID 5. Eligibility Month/Year

3. Date of Birth 6. Resource Code

1 2

1

1

1

2

2

2

3

3

3

3 4

4

4

4 5

5

5 5

6

6

6

6

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Vision Services Eligibility Verification

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Covered Services

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Fee Schedules

Fee schedules tell you:

• What services are covered

• Maximum allowed reimbursement

• Additional documentation requirements

• Other special considerations

• Fee schedules can be found on

http://medicaidalaska.com under

Documents & Forms>Fee

Schedules

• Opthalmologists should use the

Physician fee schedule

• Optometrists and Opticians

should use the Vision Services

fee schedule

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Vision Services for Children

Members under 21 years of age are eligible for:

• Complete vision exam including check of refractive state

• Additional exams if medically necessary – this requires service authorization

• Vision therapy service

• One complete pair of eyeglasses per calendar year

• One additional pair of eyeglasses if medically necessary*

– Providers must keep the reason the second pair of glasses are needed on file

– Subsequent pairs of eyeglasses require a service authorization request with written

medical justification

– Medicaid covers eyeglass repairs; in the case of broken eyeglasses, repairs should be

attempted before ordering a second pair of eyeglasses

*Medically necessary means: change in prescription, broken or lost glasses

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EPSDT - Vision Screening

• Vision screening is part of the services covered for children under Early and Periodic

Screening, Diagnosis and Treatment Services

• Screenings are provided to children at intervals as given in the Bright Futures/American

Academy of Pediatrics Recommendations for Preventive Care

• EPSDT screeners should perform a vision screening to their level of training or refer the

member to another Alaska Medicaid-enrolled provider who can complete the screening

• If screening results indicate a need for treatment of a defect, screeners must refer the child

to a vision care provider

• For more information, please refer to the EPSDT billing manual or the EPSDT program

page on the State of Alaska website.

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Vision Services for Adults

Members 21 years of age and older are eligible for:

• One complete vision exam including check of refractive state is allowed per calendar year

– Additional vision exams require a service authorization request with written medical

justification

• One complete pair of eyeglasses per calendar year

– Subsequent pairs of eyeglasses require a service authorization request with written

medical justification

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Vision Exam

A complete vision exam with a check of refractive state must include:

• Complete case history with ocular, physical, occupational, and medical data

• Determination of visual acuity with best correction determination

• External exam of eyes & adnexa

• Internal ophthalmoscopic exam

• Evaluation of ocular motility & neurological integrity

• Near point subjective exam, dynamic retinoscopy, and subjective refraction

• If clinically indicated, an ophthalmologist or optometrist should also use a phorometer to

test accommodation, convergence, and binocular coordination at far and near distances

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Contact Lens

• Contact lenses and contact lens fitting fees are covered only if the recipient is diagnosed

with one of the following medical conditions or if another medically necessary reason

exists:

– Aphakia

– Corneal degeneration

– Keratoconus

– Rejection of an implant

– Post-cataract surgery

• Exams for contact lenses must include all required components of a vision exam plus:

– Slit lamp evaluation

– Fluorescein examination

– Diagnostic evaluation (soft lenses)

• Topically administered drugs incidental to evaluations and exams are not separately

reimbursable

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Non-Covered Services

There are many services and charges that are not covered for ophthalmologists,

optometrists and opticians to include:

• Optical products provided by a non-contract supplier, except for contact lenses

• Any frames or lenses not offered by the Alaska Medicaid Vision Care program

• Progressive or no-line lenses

• Vision therapy for members 21 years of age and older

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Service Authorization

Optical services requiring authorization include:

• More than one vision exam or pair of glasses per calendar year for members age 21 or over

• More than two pairs of glasses per calendar year for members under age 21

• Specialty frames

• Tinted lenses (may be approved only with diagnosis of albinism)

• Prescribed UV coating

• All services billed using HCPCS code V2799, Vision Services, Miscellaneous

• Services on the Vision Fee Schedule requiring a service authorization

• As of June 1, 2018, all order/prescriptions submitted to Rochester Optical that require service

authorization must be accompanied by an approved Vision Service Authorization form in order to be

processed

Service Authorization Form

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http://manuals.medicaidalaska.com/docs/dnld/Form_ServiceAuth_Vision.pdf

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Classic Optical

All eyeglass lenses and frames must be ordered through Classic Optical, the Alaska Medicaid optical services contractor

• Classic Optical provides:

– 90-day warranty on lenses

– 1 year manufacturer’s warranty for frames

– Non-standard frames for special needs (service authorization required)

• Providers ordering only lenses must send the existing frames to Classic Optical to ensure proper lens fit

• Classic Optical’s business hours are 8:00 am to 9:00 pm EST Monday through Friday

• Phone number: 330.759.8245 or 888.522.2020

• Fax number: 330.759.8300 or 888.522.2022

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www.classicoptical.com

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Billing

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Pricing Methodology

• Professional services are reimbursed at the lesser of billed charges or the maximum

allowable fee as documented on the appropriate fee schedule

• Refer to the Vision Services Provider Billing Manual located at www.medicaidalaska.com

Providers> Billing Manuals>Vision

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Contact Lens – Claim Documentation

• Claims for contact lenses must be submitted with medical justification and a quoted retail

price from the manufacturer

• Claims for contact fitting fees must be submitted with medical justification

• Claims submitted without required attachments will be denied

• Claims for contact lenses must be billed using procedure code V2510, V2520, V2521,

V2522, V2523, or V2599

• One unit = a one year supply of contact lenses, per eye

• One pair of contact lenses substitutes as a complete pair of glasses

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Claims Submission Methods

There are several billing options for Alaska Medicaid vision providers.

• Alaska Medicaid Health Enterprise

• 837P Transaction (electronic claim using billing software)

– Companion Guide: http://medicaidalaska.com

– Implementation Guide (referred to as TR3): http://www.wpc-edi.com

• Payerpath (electronic claim)

• CMS-1500, Professional Health Insurance Claim Form (paper claim)

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Timely Filing

• All claims must be filed within 12 months of the date you provided services to the member

• The 12-month timely filing limit applies to all claims, including those that must first be filed

with a third-party carrier

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Third-Party Liability (TPL)

• Third-party liability is when a resource, such as an entity, carrier, individual, or program, is

or may be liable to pay all or part of a member's medical care for which Alaska Medicaid

coverage is sought

• The department will pay for a covered service, prescription drug, or supply only after the

provider has made full use of any other third-party resources available

• Before Alaska Medicaid will pay a claim, all payment amounts and or denials received from

third party sources should be included on the claim and evidence of all payments must be

attached to the claim

• Claims that must be processed by one or more third-party resources are still subject to a

12-month timely filing requirement

• Eyeglasses are TPL waivered, but other vision services do need to bill TPL before billing

AK Medicaid

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Additional Information

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Overpayments & Repayment of Payment Errors Providers should closely review each remittance advice (RA) to ensure it reflects accurate

payment for all billed services, including correct member details and services provided.

• In accordance with 7 AAC 105.220(e), Alaska Medical Assistance providers have 30 days

from the time of payment to notify the department in writing of a payment error.

• Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department

within 60 days of identifying the overpayment.

• Mail the written overpayment notification and a copy of the RA page detailing the

overpayment to the address below:

Conduent State Healthcare, LLC

P.O. Box 240807

Anchorage, Alaska 99524-0807

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Additional Resources

Alaska Medicaid Health Enterprise website at http://medicaidalaska.com.

• Information necessary for successful billing

• Includes provider-specific Medicaid billing manuals and fee schedules

You may also call:

• Provider Inquiry

– Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option

1,1,2

– Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650

(toll-free), option 1,1,1

• EDI Coordinator

– Electronic transaction assistance – 907.644.6800, option 3 or 800.770.5650

(toll-free), option 1, 4

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