New Argus Dental and Vision - 2017 VISION PROVIDER MANUAL · 2019. 8. 29. · 20. voice complaints or appeals about Argus or the care it provides. 21. make recommendations about Argus

ARGUS DENTAL & VISION, INC. 4010 W. State Street, Tampa, FL 33609 | 877-864-0625 ext. 175 | www.argusdentalvision.com PR V Manual 7/17. For Provider Use Only. © 2017 Argus Dental & Vision, Inc., Proprietary & Confidential

2017 VISION PROVIDER MANUAL

This document contains proprietary and confidential information and may not be disclosed to others without written permission from Argus Dental & Vision, Inc. Publication: 2014 Revised: August 2017

ARGUS DENTAL & VISION, INC. | 4010 W. State Street, Tampa, FL 33609 | 877-864-0625 ext. 175 | www.argusdentalvision.com PR V Manual 7/17. For Provider Use Only. © 2017 Argus Dental & Vision, Inc., Proprietary & Confidential

QUICK REFERENCE LIST Telephone # Fax # Email Address

Argus Provider Relations 813-820-4800 877-864-0625 ext. 175

813-440-4529

[email protected]

Argus Credentialing 813-400-1781

[email protected]

Argus Provider Portal portal.argusdentalvision.com

Argus Customer Care 813 864-0625 877 864-0625

813-490-0093

[email protected]

Argus Appeals 813-283- 2459 [email protected]

Argus Pre-Service Appeal 813-283-2411 [email protected]

Argus Pre-Treatment Standard

813-283-2441 [email protected]

Argus Pre-Treatment Emergency


Argus Grievances 813-283-2457 [email protected]

Argus Quality Assurance 813-283-2405 [email protected]

Argus Compliance 813-283-1276 813-347-9270 [email protected]

Argus SIU: Fraud, Waste, Abuse

813-283-1276 813-347-9270 [email protected]

Argus Vision Utilization Management


mailto:[email protected]












Table of Contents I. Introduction ...........................................................................................................................................

II. Member and Provider Rights

III. Plan Eligibility and Member ID Cards ........................................................................................................... IV. Services

General Exclusions…………………………………………………………………………………………………………………………….. Limitations ........................................................................................................................................... Covered Services…………………………………………………………………………………………………………………………. Non-Covered Services………………………………………………………………………………………………………………… Clinical Criteria Diagnostics………………………………………………………………………………………………………………………………….

V. Referral Process VI. Claims

Claim Guidelines ................................................................................................................................... Explanation of Benefit .......................................................................................................................... Claim Appeals………………………………………………………………………………………………………………………………… Claims Submission………………………………………………………………………………………………………………………… Filing Limit………………………………………………………………………………………………………………………………….. Audit of Claims…………………………………………………………………………………………………………………………… Plan participation………………………………………………………………………………………………………………………. Plan termination…………………………………………………………………………………………………………………………

VII. Professional Standards……………………………………………………………………………………………..

Pain Management Provider roles and responsibilities………………………………………………………………………………………………………… Provider Prohibited Activities Patient Record Sterilization and Infection Control Medical Emergencies

VIII. Quality Improvement Plan Credentialing…………………………………………………………………………………………… Medicaid provider eligibility……………………………………………………………………………………………………………………

IX. Provider Rights

Discipline and Termination of Participating Provider ........................................................................ Peer Review Process .......................................................................................................................... Initial Site Reviews ............................................................................................................................. Vision Record Reviews/Chart Reviews .............................................................................................. Utilization Management .................................................................................................................... Member Satisfaction Surveys ............................................................................................................ Complaint Monitoring and Trending ................................................................................................. Medicaid Fair Hearing Process


Quarterly Quality Care X. Compliance

Regulatory Requirements HIPAA Website Links to Online HIPAA Resources FWA Recall System Verification

XI. Cultural Competency Program ......................................................................................................................

XII. Plan Design Schedules

XIII. Risk Management

Forms:

Adverse Incident

Risk Management Use

Provider Application

HEDIS: Diabetic Member Management, Coding and

Documentation…………………………………………………


I. Introduction Argus Dental & Vision, Inc. is licensed through the Florida and Texas Departments of Insurance as a Pre-Paid Limited Health Service Organization (PLHSO), a Third Party Administrator (TPA) and as a Discount Plan Organization (DMPO)( in what states) Argus is the first dental plan organization in the United States to be accredited for quality care by the Accreditation Association for Ambulatory Health Care (AAAHC) and is contracted with the Florida Healthy Kids Corporation to provide affordable dental care to children in Florida. Founded by a Florida dentist to provide dental and eye care benefits that offer value and quality to members, Argus is owned and operated by professionals with extensive experience in dental and eye care insurance, clinical dentistry, and eye care. The total executive and management experience combines over fifty years of industry knowledge in dental and eye care insurance with an excellent historical record of successful, benefit implementation for millions of members. Argus has built one of the largest proprietary dental networks in the U.S. with a national partnership in all fifty states. As we expanded our services in 2013 to include eye care, our network of partnering dentists and eye care professionals continues to grow at a rapid rate. Argus regularly invests in network expansion to offer members their choice of dentists and eye care providers from over 100,000 combinations of partnering general and specialty locations. All Argus dentists, optometrists and ophthalmologists are credentialed in accordance with guidelines set forth by the National Committee for Quality Assurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS). Customer Service is of paramount importance and a key factor which differentiates Argus from other dental and eye care carriers. Our online resources, knowledgeable staff and immediate eligibility make our provider services convenient, quick and easy to incorporate into a busy practice. Through collaboration with Argus customers, HR managers, dentists, eye care professionals and insurance agents, the company has developed a wide-range of quality benefit plan designs with true value and affordable premiums supported by excellent service. Argus offers and administers prepaid dental plans, dental discount plans, dental PPO and routine vision care and medical/surgical ophthalmology services, as well as packages for individuals, families, large and small employer groups, governmental agencies, large HMO Medicare/Medicaid recipients and associations. Strengthened by its partnership with Pan-American Life and National Guardian Life (Rated A-Excellent by A.M. Best), Argus provides the coverage and security expected of a premiere dental and eye care benefits company.


immediate response. The provider should make their best effort to contact the member by the end of the same day. If a member contacts the provider’s office during the weekend, the provider should make their best

effort to contact the member when the office opens.

II. Member and Provider Rights

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. PROCEDURE: A patient has the right to:

1. be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.

2. a prompt and reasonable response to questions and requests. 3. know who is providing health care services and who is responsible for his or her care. 4. know what patient support services are available, including whether an interpreter is available if

he or she does not speak English. 5. know what rules and regulations apply to his or her conduct. 6. be given by the health care provider information concerning diagnosis, planned course of

treatment, alternatives, risks, and prognosis. 7. refuse any treatment, except as otherwise provided by law. 8. be given, upon request, full information and necessary counseling on the availability of known

financial resources for his or her care. 9. know, upon request and in advance of treatment, whether the health care provider or facility

accepts the patient’s plan benefit coverage. 10. receive, upon request, prior to treatment, a reasonable estimate of charges for health care

services. 11. receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to

have the charges explained. 12. impartial access to treatment or accommodations, regardless of race, national origin, religion,

handicap, or source of payment. 13. treatment for any emergency condition that will deteriorate from failure to provide treatment. 14. know if treatment is for purposes of experimental research and to give his or her consent or

refusal to participate in such experimental research. 15. express grievances regarding any violation of his or her rights, as stated in Florida law, through

the grievance procedure of the provider or facility that served him or her and to the appropriate state licensing agency.

16. to participate with the provider in making decisions about the health care he or she receives and provide input into planned treatment.


17. receive information about Argus, its services, providers and member/patients' rights and responsibilities.

18. participate with the provider in making decisions about his or her health care. 19. have a candid discussion about appropriate or medically necessary treatment options for your

health conditions, regardless of cost or benefits. 20. voice complaints or appeals about Argus or the care it provides. 21. make recommendations about Argus' member rights and responsibilities policies. 22. receive information about advance directives, provider’s credentials and absence of malpractice

coverage. 23. change providers if other providers are available.

A patient has the responsibility:

1. to provide to Argus and its providers, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.

2. to report unexpected changes in his or her condition to the provider. 3. to report to the provider whether he or she comprehends a contemplated course of action and

what is expected of him or her. 4. to understand his or her health problems and participate in developing mutually agreed-upon

treatment goals to the degree possible. 5. to follow the treatment plan recommended by the provider. 6. to keep appointments and, when he or she is unable to do so for any reason, will notify the

provider or facility. 7. for his or her actions if he or she refuses treatment or does not follow the provider's instructions. 8. to assure the financial obligations of his or her care are fulfilled as promptly as possible. 9. to follow facility rules and regulations affecting patient care and conduct. 10. to inform his or her provider about any living will, medical power of attorney, or other directive

that could affect his or her care. 11. to provide a responsible adult for transportation from the facility if required by the provider in

situations where sedation is administered.

Providers are required to provide services that are: 1. Not discriminating against any patient in any manner including but not limited to:

a) Source of payment b) Race c) Ethnicity d) National origin e) Sex f) Sexual orientation g) Age h) Religion i) Place of residence j) Health status k) Mental or physical disability l) Claims experience


m) Medical history n) Evidence of insurability o) Genetic information

2. Preserving patient dignity and observing the rights of patients. 3. Abiding by all administrative and medical policies and procedures established by Argus. 4. Providing all services in a culturally competent manner and accommodating patients with

disabilities. 5. Providing patients with complete information concerning their diagnosis, treatment, and

prognosis and giving them the opportunity to participate in decisions involving their health care.

Member Access As an Argus Dental & Vision, Inc. participating provider, you have agreed to open your practice to our mutual patients. In accordance with our agreement and to support our health plan and employer group commitments to provider access, please review the following access standards to assure your practice is offering these levels of service to members:

Continuous care twenty-four (24) hours/day, seven (7) days/week, including providing coverage by another network provider when not personally available.

Emergencies: Care is available immediately or referred to another more appropriate provider Urgent: Care is available within 24 hours Routine: Appointments are available within four (4) weeks. If member is offered a choice of

appointments within four (4) weeks and find none to be convenient, it is acceptable to schedule the member for the next available appointment.

After-hours emergency coverage can be provided by providing one of the options below: o Answering machine that provides the answering service or doctor’s pager number or cell phone

number o Answering machine that provides the name and contact information of another in-

network provider that covers practice in doctor’s absence o Answering service that provides immediate communication to the doctor. The doctor

then calls the patient direct. This requires the provider to communicate start/stop and the name of the doctor who will be accepting call.

When a member contacts the provider’s office and asks for a return call: Emergencies need the provider ‘s Medicaid ID number, Medicaid provider registration number or documentation of submission of the Medicaid provider registration form.

III. Plan Eligibility & ID Cards Any person enrolled in the Plan is eligible for benefits under the certificate. Member Identification Cards Members will receive either an Argus Vision ID card or will use the card issued by their health plan. Participating


providers are responsible for verifying that members are eligible for benefits prior to rendering services to the member. Possession of the card alone does not guarantee eligibility for benefits. We strongly urge you to not only confirm the member’s identity, but to confirm their current eligibility by accessing our Provider resources for eligibility verification. Please note that due to possible eligibility status changes, ID card information does not guarantee payment and is subject to change without notice. Providers are encouraged to verify member eligibility at each visit. Providers should request a picture ID to verify that the person presenting the ID card is the person named on the card. If providers suspect a non-eligible person is using a member’s ID card, please report the occurrence to Argus’ Fraud and Abuse Hotline at 813.283.1276.

Member Identification Card Sample:


Provider Eligibility Resources

The Plan offers two options to providers needing to obtain eligibility information. Those options are the customer care phone line and web portal system.

Customer Care Line Upon calling the Argus toll-free number at 877.864.0625, select option 2 and you will be directed to an Argus customer care representative.

Access eligibility information via Internet

Participating providers can access the Argus Dental & Vision Provider Portal system by logging onto portal.argusdentalvision.com and registering with their tax identification number and Payor assigned number. The portal system grants participating providers access to eligibility along with information pertaining to claims and pre-determinations. The Argus Provider Portal system also allows participating providers to submit claims and pre-determinations directly to Argus. In addition, a provider can verify a member’s eligibility while accessing the portal system.

1. Your first time on the website, you will need to register to gain full access to the Provider Portal. 2. Access will be granted immediately after registration. 3. Upon receipt of notification you may log in at the same website address as previously noted.

You will be granted access to view patient eligibility, claim information, and upload your claims. (Please wait 24 hours after registration, as access will be granted in within 24 hours of registration)

Argus requires your TIN, NPI and phone number along with the provider’s name and and/or practice name. From here, we can grant you access to your members’ eligibility and claim information.

Please note that due to possible eligibility status changes, the information provided by either system does not guarantee payment. If you are having difficulty accessing the website, please contact Customer Care at 877.864.0625.

IV. Services Please refer to the specific plan participation for covered benefits. To receive benefits, members must receive care from the participating providers. Members may be assigned to a specific vision providers or Specialist’s office to receive covered benefits.

General Exclusions: Services which, in the opinion of the treating provider, are not necessary for the patient’s eye

health. Cosmetic or experimental services or those services not typically performed in a provider’s office. Any non-network provider service including, trauma/emergency care, inpatient professional

https://argusdental.com/Provider/Provider-Portal


services, services provided at teaching facilities, covered services outside the service area. Services for which a provider is not on the network to provide. Treatment of choroidal melanoma (ICD-10 code 190.6), orbital tumors (ICD-10 codes 190.0-190.9,

and CMV Retinitis (ICD-10 code 078.5 and/or 363.13) except for the initial consultation or office visit for the purpose of diagnosis.

Ocular prosthetics: measuring, fitting, dispensing, cleaning, polishing Tissue reimbursements: Corneal tissue (CPT V2785), Pericardium tissue, Scleral tissue (CPT L8610),

Amniotic tissue (CPT V2790), artificial cornea (LPT L8609). Glaucoma Implants: Molteno implant/Ahmed implant (CPT L8612) or similar Pharmaceuticals Pathology Radiology (except ophthalmic ultrasounds (CPT 76510-76529) Hospital facility fees and anesthesia Low vision devices and services Orthotics Services not covered by Medicare and/or Medicaid or contracted health plans Services that cannot be performed because of the general health of the patient. Treatment which, in the opinion of the participating provider, must be performed by a non-

participating Specialist. Services which are not consistent with the usual and customary services provided by the

Participating General provider or Specialist. Any vision treatment started prior to the member's effective date. Any vision treatment started prior to the provider’s effective date. Services for injuries and/or conditions which are paid or payable under Worker's Compensation or

Employer Liability Laws. Services provided without cost to the Subscriber by the government or an agency thereof, or any

municipality, county and other subdivisions. Any procedure not specifically listed as a covered benefit in the Schedule of Benefits. Cost of vision care covered under any automobile, medical or no-fault or similar type insurance.

Limitations

• Certain services must be preauthorized prior to treatment. Refer to the plan’s benefit details

for detail. • Services must be individualized, specific, and consistent with symptoms or confirmed diagnosis of

the illness or injury under treatment, and not in excess of the recipient's need. • Services must reflect the level of services that can be safely furnished, and for which no equally

effective and more conservative or less costly treatment is available statewide. • Services must be furnished in a manner not primarily intended for the convenience of the

member, the member's caretaker, or the provider. • Unspecified procedures are not covered without a report demonstrating services provided

are covered under the terms of the exclusions and limitations.


Diagnostics • Reimbursement for internal diagnostics is limited to those films required for proper treatment and/or

diagnosis. • All internal diagnostics must be of good diagnostic quality, properly mounted, dated and identified with

the recipient's name and date of birth. Reimbursement for substandard internal diagnostics will not be made. Argus will recoup any payments that are determined to have been paid for substandard internal diagnostics.

• Argus utilizes the guidelines published by the Department of Health and Human Services for Devices and Radiological Health.

Covered Services Please refer to the specific plan benefit summary for covered benefits. To receive benefits, members must receive care from participating providers. Members do not need a referral and may self-refer to optometrists or ophthalmologists for routine vision or general ophthalmology services.

Non-Covered Services A provider is free to provide any services not covered by the plans; however, before doing so, the provider must inform the Member that the service(s) is not covered and advise the Member of their financial responsibility for the fee. Please refer to the Out of Network feature of the plan.

Diagnostics Diagnostic testing does not have to be pre-authorized. Some tests have coverage limitations. These limitations are based on CMS guidelines (LCD’s, NCD’s, etc.) and industry standards. Reimbursement for testing is limited to those tests required for proper diagnoses and treatment. Need for testing must be clearly documented in the medical record. Test results must be interpreted and documented with ongoing status (stable/worse/improving). Test results should be reported to the member and date of communication noted in the medical record.

A-Scan: CPT 76519 o A-scan is payable once per lifetime prior to cataract surgery. This will be paid as technical

component for both eyes, professional payment for the pre-operative eye only. Bill with an RT or LT modifier to indicate the surgical eye. When submitting the A-scan for the second eye, submit using both the -26 modifier (professional component) and RT or LT (either right or left).

Color vision testing: Not payable separately Corneal Topography: CPT 92025

o Only paid after medically necessary corneal surgery, i.e. corneal transplant, PTK, etc.). Up to three o (3) are allowed during first year after surgery.

Dark Adaptation: Not payable separately External Photos: CPT 92285

o Only reimbursed for approved blepharoplasty, ptosis repair and pterygium-removal procedures. (See clinical guidelines.)

Eye Allergy Assay Testing: Not payable separately Fluorescein Angiography: (92235)

o We pay 100% on the initial eye and 50% on the second eye when performed on the same day. A combination of four (4) FA’s or SCODI’s is paid per year.

Fundus Photography: CPT 92250


o Since scanning computerized ophthalmic diagnostic imaging (SCODI) gives both similar and improved results, the provider should choose which test is best suited to the member’s circumstances. Argus will reimburse for one (1) fundus photo each year. Fundus photos will not be reimbursed if performed on the same day as SCODI. Unilateral photos are paid at 50% of the contract rate. CPT codes 92225and 92226 are not payable with 92002-92012, 92004-92014, 99201-99205, 99211-99215.

Glare testing: Not payable separately Gonioscopy: CPT 92020

o Routine gonioscopy is considered part of the comprehensive eye exam. However, one (1) per lifetime is reimbursed for these conditions: open angle glaucoma (baseline), suspicion of neovascular glaucoma, angle recession or pigmentary glaucoma.

Pachymetry: CPT 76514 o This test includes both eyes and will not be reimbursed separately per eye. Argus will

reimburse for one (1) per lifetime. Pachymetry will not be reimbursed for patients with an established glaucoma diagnosis.

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI): CPT 92132-92134 o These codes are bilateral. o 92132 – Anterior Segment – Due to an opaque cornea, structural abnormalities may not be

visible unless identified by this scan. Not covered if related to refractive surgery. o 92133 – Posterior Segment – to detect structural damage to the optic nerve or nerve fiber layer.

Allows early diagnosis or determination of glaucoma progression or other optic nerve disease. Medical necessity is based on evidence of signs and symptoms of glaucoma or other optic nerve pathology and medical history. This test should not be used for screenings or preventative health services.

o 92134 – Posterior Segment, Retina – Used to identify presence of intra- and sub-retinal pathology. Combined with 92235 only four (4) of these two tests are reimbursed each year. We will consider more frequent usage of 92134 if the patient is in active intravitreal treatment with anti-VEGF drugs to monitor the treatment response.

Serial Tonometry: CPT 92100 o Please submit chart notes with the claim that show progressive glaucomatous changes

with normotensive IOP. Specular Microscopy: CPT 92286

o Before and after corneal transplant surgery Potential Acuity Measurement (PAM): Not payable separately Refraction: CPT 92015

o A refraction is considered bundled in the exam payment for both routine and medical evaluations. o Post-op refraction is included in the global period for cataract surgery.

Visual Field Testing: CPT 92081, 92082, 92083 o Fields are typically performed and paid as a bilateral procedure, requiring no modifier unless

only one eye is tested. Reimbursement is adjusted accordingly. No more than 1 visual field is reimbursed each year unless the patient’s condition requires additional testing and the reason is documented in the chart. Visual fields are not reimbursable for diagnoses of blepharoplasty, dermatochalasis or ptosis. (See clinical guidelines.)

Modifiers: RT (right eye) and LT (left eye) should be used on all unilateral diagnostic testing to designate which

eye is being tested. Without these modifiers claims will not be considered for payment. 26 (interpretation and report) TC (technical component)


50 (bilateral services) 52 (reduced services) If only one eye is completed on a test that is considered bilateral for payment, use

this modifier. Reimbursement is 50% of the contracted rate. This modifier may also be used if a procedure was not completed.

E1 – Left upper eyelid E2 – Left lower eyelid E3 – Right upper eyelid E4 – Right lower eyelid

Office Visits Comprehensive Eye Exams: 92004 (new patient) and 92014 (established patient) Please check individual plan Benefit Summaries as not all companies cover routine eye examinations and some, like Medicaid, provide only periodic coverage, rather than annual. We strongly suggest that you verify eligibility and member identity prior to rendering services. Member co-pays should be collected at the time of service. Please bill using codes 92004 or 92014 with an appropriate routine ICD-10 code. Medical diagnoses should also be included, but they should be billed secondary to the routine diagnoses. Argus requires inclusion of PQRS codes to indicate that certain services that meet important quality measures were performed. (See clinical guidelines.) No prior authorization is required.

Members seeking services because “It was time for my annual eye exam” or “I need new eyeglasses” are not medical and should be billed as routine eye exams. Members with symptoms of eye health problems should be billed as medical.

An eye examination is to be performed in accordance with all current and future American Academy of Ophthalmology (ABO) Preferred Practice Patterns, American Optometric Association (AOA) Clinical Practice Guidelines, State Board of Optometry Practice Standards and local community professional standards. All findings and test results must be recorded in a legible, clear manner. The eye examination is to include (at minimum) the following:

1. Medical/ Eye History

• A complete chief complaint that clearly depicts any eye or visual problems. • Age • Medications • Family history • Significant visual changes

2. Visual Acuities • Entering, with or without correction, as applicable (distance and near) • Best corrected vision with final subjective RX (distance and near)

3. Motility Assessment 4. Confrontational Visual Fields 5. Pupil and pupillary reactions 6. Refraction: includes final subjective refraction 7. External Examination

• Lids


• Conjunctiva

• Cornea

• Crystalline Lens • Anterior Chamber depth • Media clarity

8. Intraocular Pressure • Must include the method used for obtaining pressures and time of day.

9. Ophthalmoscopy- direct/ indirect • A dilated examination of the retina and peripheral retina is to be performed and

documented whenever professionally indicated • Document all findings in the vitreous, macula, optic nerve, including C/D ratio, and retinal

vessels. 10. Diagnosis and treatment plan. 11. If a routine exam, refraction is considered included. A prescription for eyeglasses should be given to the

member.

Sensorimotor Exam (92060) and Extended Ophthalmoscopy (92225, 92226) are considered bundled services with the comprehensive eye exam and are not reimbursed separately.

Evaluation and Management codes: 99201-99205 (new patient) and 99211-99215 (established patients) Evaluation and Management or medical office visits are only rendered by a medical panel provider. All relevant ophthalmic and systemic diagnoses should be billed on the claim with these procedures. Be sure to also bill the appropriate PQRS code (see clinical guidelines). These exam codes are for medical issues and are not appropriate to use for routine eye exam services. Any routine diagnoses should be billed on the claim following all applicable medical diagnoses.

Consultations: Only payable under the Medicaid program, a consultation must contain 3 important elements: A request from one provider to another for an opinion A report from the consulting provider to the requesting provider after the consult A return of the member back to the requesting provider for treatment. If the consulting provider

assumes the care of the member then a consult cannot be billed.

Referrals within a group practice If one provider in a group practice refers a patient to another in the same group practice, services will be reimbursed at established patient levels for the second provider and with consideration for the fact that may have the exam components have already been performed and documented.

High Level Evaluation and Management Codes When submitting claims for level 4 and 5 evaluation and management codes, please be sure that documentation supports the level of coding. Collection of data that is not pertinent to the visit is not considered when determining the coding level. Audits on these exam codes are performed periodically using the CMS and AAO coding tools. This level of coding may be appropriate for members with complicated medical situations involving multiple diagnoses and system issues, but national utilization patterns show that most services are appropriately billed at level 3 or less.


Use of PQRS codes:

Collection of this data is vital to fulfilling CMS reporting requirements. Therefore, it is considered mandatory and will be a requirement of “clean claims”. Office visit claims without a PQRS code will be rejected.

Services and Pharmaceuticals that require Pre-Authorization:

CPT/HCPCS Code Description 11440-11446 Excision of Lesions (Skin tag removal is NOT covered CPT 11200-11201) 15820-15823 Blepharoplasty 65710-65755 Corneal Transplant 65772 Corneal relaxing incision for correction of surgically induced astigmatism 65781-65782 Ocular surface reconstruction; gimbal stem cell allograft (e.g. cadaveric or living donor) 65855 Laser Trabeculoplasty 66170 Trabeculectomy 66761 Laser Iridotomy 66821 YAG Laser Capsulotomy 66830-66940, 66982-66986

Cataract Extraction and Related Procedures

67311-67345 ADULT Strabismus Correction (patients older than 21) 67840-67850 Excision of Lesions (Skin tag removal is NOT covered CPT 11200-11201) 67900-67914, 15822, 15823

Ptosis and Blepharoptosis Repair

67999 Unlisted procedure, Eyelids J0585 onabotulinumtoxin A (Botox®) J0586 abobotulinumtoxin A (Dysport®) J0587 rimabotulinumtoxin B (Myobloc™) J2503 Macugen® J2778 Lucentis® J3396 Visudyne® J7312 Ozurdex® J0178 Eylea® J7316 Jetrea® Q2040 incobotulinumtoxin A (Xeomin®)

The Argus Pre-Authorization Request form must be completed and faxed to Argus Dental and Vision at 813-792-3359 with supporting clinical information in order for the procedure to be considered for authorization.

Please submit requests for pre-authorization fourteen (14) days prior to the date of service. Argus will either approve or deny services within the CMS approved time frame of ten (10) business days upon receipt of completed request and supporting documentation. It is important to complete all fields on the form, especially the contact information as we may need to contact you for additional information or to consult with the treating physician.

A response will be faxed with either an approval or denial. If the procedure is authorized, the approval will be valid for ninety (90) days. Please include the authorization number in field 23 on your billing form.


If the procedure is denied, you may appeal the decision. The appeal process will be communicated in a letter direct from the member’s health plan. Doctor to Doctor Discussion If your request has been denied, the physician who made the decision to deny is available to talk to the member’s attending provider (or their staff) via phone call, about the services requested within 24 hours. This teleconference is available at the attending provider’s request. Billing Different Codes than Authorized If a procedure performed is different than the procedure that was pre-authorized or when additional procedures are required in the course of performing the surgery, please send operative notes with the claim to support the difference. The case will be reviewed with the additional information to determine reimbursement or denial of the additional or different procedures.

Urgent Treatment authorizations Urgent treatment is care needed for an acute condition or a stabilized chronic condition that may adversely affect either the health or function of the member if care is not urgently administered. Urgent care is typically needed within 24 hours. Urgent is not to be marked on the pre-authorization form for scheduling purposes. Urgent is only to be used to describe the medical necessity for care within 24 hours.

Urgent care may be needed if:

The member is out of town, or The member has an issue outside the normal business hours of in-network providers, or

Argus will cover urgent care without pre-authorization when it is not possible for physician and/or staff to arrange for prior approval. Documentation is required regarding the nature of the issue and the reason why prior-authorization was not possible.

Emergency Treatment authorizations The Florida Statutes section 409.901(9) defines an emergency condition as: (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent layperson, pursuant to Section 4704 of the 1997 Balanced Budget Act, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: 1. Serious jeopardy to the health of a patient including a pregnant woman or a fetus. 2. Serious impairment to bodily functions. 3. serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman: 1. That there is adequate time to effect safe transfer to another hospital prior to delivery. 2. That a transfer may pose a threat to the health and safety of the patient or fetus. 3. That there is evidence of the onset and persistence or uterine contraction or rupture of the membranes which results in medical screening, examination and evaluation by a physician, or, to the extent permitted by applicable laws, by other appropriate personnel under the supervision of a physician, to determine whether an emergency medical condition exists, and the care, treatment, or surgery for a covered service by a physician which is necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital. This includes covered services that are both furnished by a physician qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.

Argus will cover emergency treatment to screen or stabilize patients without a pre-authorization as defined above.

Reimbursement for Urgent Care when a Pre-Authorization was required The key to obtaining reimbursement for unauthorized urgent or emergent services is communication and documentation. Notify us as soon as possible following the treatment. Send a completed pre- authorization


form with medical records to our Utilization Management team for review. Most of the services, with the exception of pharmaceuticals, that require pre-authorization are not typically performed on an urgent or emergent basis, so this scenario should be a rare occurrence.

Pharmaceuticals Please see individual plan benefit summaries regarding coverage and pre-authorization requirements as these may vary by plan.

Facility Pre-Authorization Procedures performed in ambulatory surgery centers must be registered in order for the facility to be paid. Only in-network surgery centers should be used.

If you are requesting authorization for a procedure, please also complete the facility information on the Pre-Authorization Request form. Complete the facility’s phone and fax and we will send them a copy of authorization.

Please allow 14 days for any facility authorization, excluding urgent and emergent cases. Procedures may be denied if not sent within the specified time period.

If the procedure is denied, a copy of the denial will not be sent to the facility. If you are performing services at an ASC that do not require a pre-authorization, please complete the pre- authorization request form and check the “Facility Only” box so that we may send an authorization to the facility. You may then proceed with the services.

If you are performing a service at a hospital (e.g., retina surgery at a hospital) please contact us so that we may coordinate the authorization for the hospital with the health plan.

Argus does not reimburse for facility for procedures typically performed in the office setting. These services may include, but are not limited to:

Angiography Fundus photography A-scans, B-scans Visual Fields

If a provider does not have the equipment to perform certain procedures in-office, the member must be referred to a different in-network provider.

Argus has made its best effort to contract with facilities used by our in-network providers. In-network providers should assure in advance that they have privileges at in-network facilities.

Surgical Billing Global Billing Surgical procedures, whether performed in-office or in a facility are assigned a “global period”. The global period is a length of time, either 0, 10 or 90 days following the surgery during which all related post- operative services are included in the fee for the surgery. The global period also includes a pre-op visit the day of the surgery. Some examples of items bundled into the global period according to CMS:

Post-op refraction is included in the global period for cataract surgery. Office visit during the global period when patient is returning for a planned procedure is post-op

for one surgery and pre-op for the other. Paracentesis (CPT 65805) to relieve intra-ocular pressure after cataract surgery is bundled in the

surgery


Office visits within the global period will not be paid unless they are a separate and distinct service. Please use modifiers to indicate this. Diagnostic testing within the global period will be carefully studied to assure it is medically necessary. Documentation should strongly support billing of this type during the global period.

Multiple Procedures When more than one surgical procedure is performed, it is appropriate to reduce the amount paid on supporting procedures. The primary surgery code (one with the highest dollar value) will be paid at 100% of the contract rate; subsequent codes will be paid at 50% of contract rate; and each succeeding code (up to 5) will be paid at 25% of contract rate. Operative reports are required to support multiple procedure billing. Please use modifier -51 on supporting procedures. Bilateral Procedures For surgeries performed bilaterally, please use modifier 50. Payment will be made at 100% of the contracted rate for the first eye and 50% for the second. Mutually Exclusive Procedures Argus follows CMS’ CCI edits and does not allow reimbursement of mutually exclusive procedures, bundling or any other form of redundant coding.

Punctal Occlusion Collagen plugs, used to temporarily block tear ducts, and their insertion are considered part of the diagnostic work-up and not reimbursed separately. CPT code 68761 should be used to bill permanent punctal plugs. Please use E1-E4 modifiers to indicate the puncta. The plug itself is bundled with the insertion fee and not billable separately. Only one replacement per punctum is allowed per lifetime.

Office Visit on the Same Day as Major Surgical Procedure An office visit is not payable on the same day as major surgery as it is considered part of the global pre-op. If the patient is new and the decision for the surgery is made during the office visit on the same day as the surgery, the office visit may be billed using modifier -57.

Modifiers In addition to the modifiers already mentioned, these modifiers may assist in communicating special situations in billing that may secure reimbursement:

RT (right eye) and LT (left eye): Use these to indicate which eye for diagnostic testing and surgeries. Claims may be denied without these modifiers.

-25 Separately identifiable evaluation and management service by same physician on same day of procedure or other service: CMS claims that this modifier is the most widely overused and misused modifier. The modifier is to be used on office visits that are distinct and separate from the reason a member is having a procedure the same day. The office visit should be pointed to a different diagnosis than the procedure. These will be monitored closely and reductions in fees may be applied to the office visit.

-26 Professional component (interpretation and report) and TC Technical component to indicate which part of a diagnostic test is done.

-50 Bilateral Services: Reimbursement on the first eye is 100% and the second is 50% -51 Multiple Surgery: Multiple surgeries on the same day as a major surgical procedure should be billed

with the -51 modifier. Bill the primary surgery without the modifier and the additional surgeries with it. Primary procedure is paid at 100%, secondary procedure at 50% and others (up to 3 more) at 25%. If


there are additional procedures the operative report will be reviewed to determine if additional reimbursement is due.

-52 Reduce Services: Use this modifier to indicate an incomplete procedure such as a bilateral test performed on one eye only, or a surgical procedure that was not completed. Payment reductions apply for reduced services.

-54 Surgery only: Surgical procedures are broken into three (3) components: pre-operative, intraoperative and post-operative. Use this modifier to bill for the pre-op and intra-operative components. This would be used if another provider performed the post-op component. Reduced payment is reimbursed.

-55 Post-op only: Use this to bill for the post-operative component only. Reduced payment is reimbursed.

-57 Office visit on same day as surgery: For billing an office visit for a new patient when the decision to do surgery is made at that visit and the surgery is done on the same day. We pay 75% of the contract for the office visit.

-78 Return to the Operating Room During the Global Period: If there are complications related to the original surgery and the patient needs to be taken back to the operating room to resolve, use this code to bill the procedures. Please be careful to follow pre-authorization rules. Claim will be considered for payment at a 50% payment reduction.

-79 Unrelated Service During Global Period: Use this to bill a service that is not related to the original surgery when the patient is still in a global period. Please be careful to follow pre- authorization rules.

Clinical Guidelines Clinical Guidelines are based upon these three objectives: We strive to base our decisions on appropriate levels of care, with the appropriate provider at the

appropriate time. We strive to partner with our participating providers including them in decision-making to assure a

consistent, appropriate and cost-effective care delivery system. We strive to be rational and not create unnecessary administrative burden for our providers.

Argus believes there must be a partnership between the health plan and the physician for cost-effective, quality patient care. We strive to minimize the administrative burden on physician staff and in turn hope to minimize inconvenience to the member, as well. Our pre-authorization process applies just to those services where there is a high degree of variation in the application of clinical guidelines. These services are limited in number and reviewed to assure consistent application of clinical guidelines.

When Clinical Guidelines do not apply Argus’s clinical guidelines stem from commonly accepted standards of care. They are reviewed on an ongoing basis by our Clinical Guidelines Committee. We expect that each provider of care will act in each patient’s best interest. However, we also expect that each provider of care will provide a complete, legible document of the unique medical issue, all clinical data that defines the presenting issue and the procedures performed. Argus will review the entire case to assure that medical necessity was supported. If the procedure is not supported by the clinical documentation, retrospective payment recovery may be implemented.


Quality Initiatives Argus’ quality initiatives are important to assure the provision of excellence in eye care. Our Quality and Compliance Committee oversees all of Argus’ clinical and operational matters. These include, but are not limited to: Clinical Guidelines: Developed by our provider committee, these guidelines provide a standard of care

used to promote continuous improvement in the delivery of care. Quality Improvement and Compliance: Evaluation and monitoring quality and efficacy of care, while

providing processes to ensure quality levels are met or exceeded. Advanced Technology Developments: While Argus does not reimburse for services that are deemed

experimental or investigational, we acknowledge that these new services are the gateway for possible improvements to care. Argus’ clinical team works with their counterparts at each health plan to assess advanced technological developments for appropriateness and possible coverage.

Physician Administered Pharmaceuticals

National Drug Codes (NDC) are required for billing for pharmaceuticals administered by physicians, outpatient hospitals and dialysis centers. Please use the correct HCPC code, the NDC code and the amount administered.

For paper claims, the NDC code, unit of measure and quantity should be entered in box 24a of the HCFA claim. Please use the actual NDC code from the package from which the drug was administered. Enter the qualifier N4, immediately followed by the 11-digit NDC number, immediately followed by 2-digit unit of measure qualifier, immediately followed by the unit quantity. The correct format is as shown below:

N412345678901ML10.5

Measurement qualifiers: F2 = International unit

GR = Gram ML = Milliliter UN = Units

If you must report multiple NDCs on a claim, enter a KP modifier for the first drug and KQ for each subsequent NDC.

If a pre-authorization number is required, please remember to include it in box 23 of the HCFA claim form.

Ordering from Pharmacy Vendor

Injectable drugs may be ordered from the health plan’s pharmacy vendor Oncology Plus. To order from Oncology Plus a pre-authorization must be submitted to Argus stating it is also a pharmacy order. Once authorized, Argus will send the authorization to Oncology Plus.

Physicians who wish to order injectable drugs from their own vendor are also welcome to do so.

Labeler Code

Product Code

Size Code

Unit of Measure

Units Dispensed


List of Procedures and Conditions The following pages describe eye care procedures and conditions that require thoughtful consideration. Each procedure or condition will describe the medical scenario, provide required chart documentation, list the covered diagnoses and suggested coverage conditions. We acknowledge that each member is unique and some situations may not fall within the parameters of the guidelines included here. Please feel free to contact our medical management team to discuss a unique situation that may require an exception. If our medical management team is unable to provide a satisfactory explanation, a one-on-one discussion with one of our medical directors or a review by our clinical standards team may be in order.

The following procedures and conditions are discussed: Cataract Extraction YAG Laser Capsulotomy Blepharoplasty and Ptosis Repair Comprehensive Eye Examination Corneal Pachymetry, Corneal Relaxing Incision, Corneal Topography, Corneal Transplant Diagnostic Testing Laser Iridotomy Laser Trabeculoplasty Laser Trabeculectomy Lid Lesion Excision Medicaid Benefits Ocular Surface Reconstruction Pediatric Eye Care Pharmaceuticals in Eye Care Pterygium Excision with or without Graft Strabismus Correction, Adult

CATARACT EXTRACTION CPT code(s): 66982, 66984, 66985, 66986

The following criteria must be met and included in the documentation submitted for pre- authorization:

o History: Demographic data, other health care providers, present status of visual function, ocular symptoms, ocular history, systemic history, medications, allergies or adverse reaction to medications, family history, social history, review of ocular systems.

o The member should demonstrate some disability or impairment that inhibits them from carrying out daily activities as a direct result of the cataract. This may include but is not limited to: reading, watching television, driving, or meeting occupational or vocational expectations. The member’s perception of the impact of their visual disability on lifestyle such as loss of independence should also be documented. The chief complaint must include affected eye, duration of the vision impairment as well as a glare complaint and related functional impairment, if any.

o The member’s entering distance visual acuity with correction if applicable. If any impairments or complaints relate to near vision, also measure and document visual


acuity with correction if applicable. o Manifest refraction with best corrected distance and near visual acuity should

also be documented. Per CMS guidelines, the best corrected visual acuity in the affected eye should be worse than 20/40.

Glare/BAT testing using the medium illumination setting should be measured through the best refractive correction if there is a glare-related chief complaint or if the best corrected vision is 20/40 or better. Glare testing must show a decrease in visual acuity of more than three lines in order to be considered. Glare/BAT testing alone is not an indication for surgery, however exceptions may be made if the member presents with significant posterior sub-capsular opacification or cortical spokes in the visual axis.

Pinhole acuity and/or PAM may be included to demonstrate retinal potential. The results of the eye examination confirm that the cataract is the cause of the vision

impairment. Potential for improved visual outcome that is expected to resolve the member’s complaints must be demonstrated.

The member must undergo an ophthalmic evaluation that documents a description and the degree of the present cataract. The results from a dilated fundus exam including macular detail must also be included in order to rule out other eye diseases that may cause decreased visual function.

Cataract surgery may be covered when there is an impeded view of the fundus that inhibits proper management of diseases affecting the posterior segment of the eye.

The following conditions will also be considered medically necessary indications for cataract surgery: Lens-induced disease such as phacomorphic glaucoma, phacolytic glaucoma,

phacoanaphylatic endophthalmitis, or a subluxated lens. Symptomatic anisometropia of three diopters or greater that is not intentionally created by

cataract surgery. If anisometropia is intentionally created, such as in members with monovision and there is no visually significant cataract, then surgery for the second eye is considered refractive and will not be covered.

Members must be educated regarding all risks, benefits and alternative treatments regarding cataract surgery. If a refractive change will resolve the member’s visual complaint(s) and related functional impairments, it should be provided and the member reassessed at a future visit for impairment due to lens opacification before considering surgery. The member’s medical and mental health must also allow the surgery to be safely performed.

Red flag on Complex Cataracts: 66982 is used to indicate distinct procedural differences requiring devices or techniques not generally used in routine cataract surgery, including: An iris expansion device placed in the eye due to inadequate pupil dilation and remaining in the eye during

the cataract removal A capsular tension ring indicated in the presence of insufficient support Suture support for the intraocular lens Primary posterior capsulorrhexis Patients in the amblyogenic development stage

Intraoperative complications such as vitreous loss, synechiolysis, and iris prolapse do not qualify a procedure as complex. According to CMS statistics, only 1.5% of all cataract surgeries actually meet the criteria to be considered “complex”.

Sources: -Medicare Local Coverage Decision# L3308“Cataract Extraction”, effective October 2015 -Cataract in the Adult Eye, American Academy of Ophthalmology Preferred Practice Pattern, 2008 -© Riva Lee Asbell, Ocular Surgery News, May 2004


-Ocular Pathology, Myron Yanoff, MD and Ben Fine, MD, 1975

YAG LASER CAPSULOTOMY CPT Code: 66821

All of the following conditions must be present: The member should demonstrate some disability or impairment that inhibits them from

carrying out daily activities as a direct result of opacification of the posterior capsule of the lens.

Potential vision improvement is anticipated to relieve vision complaints Best corrected visual acuity of 20/30 or worse and expected improvement of 2 or more lines

on the chart o If the best corrected vision is 20/20 or 20/25, then a decrease in visual acuity of more than 2

lines on the chart must be demonstrated by glare or BAT testing using a medium illumination setting.

The results of a dilated fundus exam must be submitted to rule out any concomitant eye diseases that may be the primary cause of vision loss in the affected eye.

Or the following condition must be present:

Opacification inhibits an examination of the fundus

YAG laser capsulotomy is not indicated if vision can be functionally improved by a change of spectacles or if visual impairment is secondary to a condition other than posterior capsule opacification. Sources: Cataract in the Adult Eye, American Academy of Ophthalmology, Preferred Practice Pattern, 2008 CMS, LCD# L33968 YAG Laser Capsulotomy, October 2015

UPPER EYELID BLEPHAROPLASTY CPT Codes: 15822, 15823

The member must present with a visual impairment and/or decreased visual field as a result of excess skin weighting down on the upper lashes (dermatochalasis or blepharochalasis).

• Ptosis must be ruled out as the primary cause of visual field obstruction • Color photographs must be taken at eye level with the patient in primary gaze with a relaxed,

normal eyelid position. If peripheral vision is impaired, also document any lateral hooding that is present with side views. Photos must show:

• The extra skin, but not the lid margin, taped up to show it corrects any visual field obstruction OR

• The upper eyelid skin touches the lashes or indicates the presence of chronic dermatitis.

• The upper eyelid position causing difficulties tolerating a prosthesis in an an ophthalmic socket.

UPPER EYELID BLEPHAROPTOSIS REPAIR AND BROW PTOSIS REPAIR CPT Codes: 67900-67909

Argus will consider upper eyelid blepharoptosis and brow ptosis repair medically necessary when the following criteria are met:


• The patient must demonstrate a functional and visual impairment as a direct result of their eyelid positioning.

• Other causes of ptosis must be ruled out including but not limited to recent Botox or similar injections within the past 6 months or myasthenia gravis.

• A marginal reflex distance of 2.0 mm or less must be documented in the member’s clinical notes as well as in color photographs with the eyes in primary gaze and the eyelids in a relaxed, normal position.

• Brow ptosis must be documented in two color photographs, one showing the eyebrow below the bony superior orbital rim and the second which demonstrates that taping up the brow alleviates any visual field disturbances.

COMPREHENSIVE EYE EXAM CPT codes: 92002, 92012, 92004, 92014

Chief Complaint: Patients may or may not have ocular conditions, previously identified conditions or risk factors, recurrent or new symptoms. Frequently the patient will request this service to obtain a prescription for eyewear or to have their periodic eye examination.

Components of Service: History: demographic data, other health care providers, present status of visual function, ocular

symptoms, ocular history, systemic history, medications, allergies or adverse reaction to medications, family history, social history, review of ocular systems.

Examination: visual acuity with current correction at distance and near, measurement of best corrected visual acuity with refraction, confrontation visual fields, external examination, pupillary function, ocular alignment and motility, biomicroscopic examination, intraocular pressure measurement, fundus examination, assessment of relevant aspects of the patient’s mental and physical status. New patients should have a dilated fundus examination unless contraindicated and subsequent examinations should be dilated as medically indicated and if requested by the patient.

Red Flag: These services are to be used for routine eye exam services. If used for a medical office visit, the documentation must support the use of the code. Please place the appropriate diagnosis code in the primary position to indicate the type of exam performed based on the patient’s presentation. Diagnosis codes listed in the table on page 10 will be considered routine.

Red Flag: Refraction (92015) is considered as included in this code and should not be billed separately to Argus, the member, or the health plan.

Description ICD-10 codes Vision exam, normal state Z01.00 Exam without abnormal findings Z01.01 Exam

with abnormal Hyperopia H52.00 Hyperopia, unspecified eye H52.01

Hyperopia, right eye H52.02 Hyperopia, left eye H52.03 Hyperopia, bilateral

Myopia H52.10 Myopia, unspecified eye H52.11 Myopia, right eye H52.12 Myopia, left eye H52.13 Myopia, bilateral


Regular Astigmatism H52.221 Astigmatism, right eye H52.222 Astigmatism, left eye H52.223 Astigmatism, bilateral H52.229 Astigmatism, unspecified

Irregular Astigmatism H52.211 Irregular Astigmatism, right eye H52.212 Irregular Astigmatism, left eye H52.213 Irregular Astigmatism, bilateral H52.219 Irregular Astigmatism, unspecified

Anisometropia H52.31 Anisometropia Aniseikonia H52.32 Aniseikonia Presbyopia H52.4 Presbyopia Paresis of accommodation H52.521 Paresis of accommodation, right eye H52.522 Paresis of

accommodation, left eye H52.523 Paresis of accommodation, bilateral H52.529 Paresis of accommodation, unspecified eye

Spasm of accommodation H52.531 Spasm of accommodation, right eye H52.532 Spasm of accommodation, left eye H52.533 Spasm of accommodation, bilateral H52.539 Spasm of accommodation, unspecified eye

Unspecified refractive disorder H52.7 Unspecified refractive disorder

COMPUTERIZED CORNEAL TOPOGRAPHY CPT code: 92025

Indications and Limitations of Coverage and/or Medical Necessity: Possible covered conditions may include: pre-operatively for evaluation of irregular astigmatism prior to cataract surgery monocular diplopia bullous keratopathy post surgical or post traumatic astigmatism, measuring at a minimum of 3.5 diopters post penetrating keratoplasty surgery post surgical or post traumatic irregular astigmatism complications of transplanted cornea post traumatic corneal scarring keratoconus pterygium and/or corneal ectasia that causes visual impairment

Limitations Corneal topography will only be allowed for a pre-operative cataract patient if documentation

supports that the patient has irregular astigmatism Corneal topography is a covered service for the above indications when medically reasonable and necessary

only if the results will assist in defining further treatment. It is not covered for routine follow- up testing. Repeat testing is only indicated if a change of vision is reported in connection with one of the above listed

conditions. Services performed for screening purposes or in the absence of associated signs, symptoms, illness or injury

as indicated above will be denied as non-covered. Corneal topography will be non-covered if performed pre- or post-operatively in relation to a Medicare non-

covered procedure, i.e., LASIK or other refractive procedure. Per CMS Pub 100-03, Chapter 1, Part 1, Section 80.7, refractive keratoplasty is surgery to reshape the cornea of the eye to correct vision problems such as myopia and hyperopia.


Refractive keratoplasty procedures include keratomileusis, keratophakia, and incisional keratotomy. The correction of common refractive errors by eyeglasses, contact lenses or other prosthetic devices is specifically excluded from traditional Medicare coverage. The use of radial keratotomy and/or keratoplasty (refractive surgeries) for the purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or contact lenses, which are specifically excluded by §1862 (a)(7) of the Act (except in certain cases in connection with cataract surgery). In addition, many in the medical community consider such procedures to be cosmetic surgery, which is excluded by §§1862 (a)(10) of the Act. Therefore, keratoplasty (refractive surgeries) to treat refractive defects is not covered.

Documentation Requirements: Medical record documentation submitted by the ordering/referring physician must indicate the medical necessity for performing the procedure and the results and interpretation derived from the corneal topography. This information is usually found in the history and physical, office/progress notes and the computerized corneal topography imaging interpretation and report. Corneal topography is used to manage post-operative astigmatism following corneal transplant by partial anterior or full thickness keratoplasty. Up to three (3) corneal topographies will be allowed in the first post-op year with no need to pre-authorize. Pre-authorization is required for additional services and documentation must support the request. Source: CMS LCD# L33810

CORNEAL PACHYMETRY CPT code: 76514 Indications and Limitations of Coverage and/or Medical Necessity: May be covered for confirmation of intraocular pressure in a patient where the diagnosis of glaucoma and adjustments in treatment are considered. Not covered for patient with an established glaucoma condition where treatment is successful. This service is covered once per lifetime. If the patient is referred to a specialist, the medical records should be forwarded to the specialist for review so no services are duplicated. Sources: Primary Open Angle Glaucoma, American Academy of Ophthalmology Preferred Practice Pattern, 2006 Primary Open Angle Glaucoma Suspect, American Academy of Ophthalmology Preferred Practice Pattern, 2008 Ducker David, Singh Kuldley, Lin Shan, Fechtner Robert, Minckler Don, Samples John, Schuman Joel: “Corneal Thickness Measurement in the Management of Primary Open-Angle Glaucoma: A Report by the American Academy of Ophthalmology”, 2007 September vol. 114 (9) 1779-1787.

CORNEAL RELAXING INCISION CPT codes: 65772 Indications and Limitations of Coverage and/or Medical Necessity: Procedure will be covered to resolve surgically induced astigmatism as a result of cataract surgery, medically necessary refractive surgery, scleral buckling for retinal detachment, or corneal transplant. The following conditions must exist:

astigmatism is > 3.0 D the medical record shows related complaints about restrictions on daily living activities


spectacles or contact lenses do not correct the vision The procedure is not covered for astigmatism related to any type of non-medically necessary refractive procedure such as LASIK. Source: http://crstoday.com/PDF%20Articles/0506/CRST0506_09.htm, Louis "Skip" D. Nichamin, MD

CORNEAL TRANSPLANT CPT codes: 65710-65757 Indications and Limitations of Coverage and/or Medical Necessity: Covered conditions may include: Diseases of the cornea such as cornea estasia, corneal edema, corneal opacification, tectonic grafting Any condition threatening perforation of the cornea, i.e. uncontrolled infection Decreased visual function secondary to corneal disease, i.e., bilateral 20/50 or worse (best corrected) or

unilateral 20/80 or worse (best corrected) Failure of keratoconic contact lens (e.g. Soper, Rose-K, scleral) to permit adequate visual function in

keratoconus patients. Not covered: Extremely limited or no visual potential Absence of patient generated lifestyle impairment complaints due to visual impairment

Corneal topography (92025) is used to manage post-operative astigmatism following corneal transplant by partial anterior or full thickness keratoplasty. Up to three (3) corneal topographies will be allowed in the first post-op year with no need to pre-authorize. Pre-authorization is required for additional services and documentation must support the request.

Sources: Gupta Nakul, Carlson Alan: Keratoconus: Diagnosis and Management Ophthalmic Pearls: Cornea 2009 Randelman J Bradley, Song C Diane, Palay David: “Indications for and outcomes of penetrating keratoplasty by resident surgeons” American Journal of Ophthalmology: 2003 July vol 136 (1) 68-75 Claesson M, Armitage WJ, Fagerholm P, Stenevi U: “Visual outcome in formal grafts: a preliminary analysis of the Swedish Corneal Transplant Register, British Journal of Ophthalmology 2002 February vol. 86 (2)174-180

DIAGNOSTIC TESTING EXTERNAL OCULAR PHOTOGRAPHY CPT code: 92285 Indications and Limitations of Coverage and/or Medical Necessity: Covered conditions may include:

Functional impairment caused by eyelid malposition such as ptosis or blepharochalasis Neoplasm of the eyelid, adnexa, or anterior segment Progressive pterygium

Color photographs can be submitted in either prints or slides. Encrypted digital color images are preferred and should be submitted using a secure e-mail method to protect patient privacy. Source: CMS LCD# L33819 External Ocular Photography, October 2015

http://crstoday.com/PDF%20Articles/0506/CRST0506_09.htm


INFLAMMA DRY (IMMUNOASSAY FOR ELEVATED LEVELS OF THE MATRIX METALLOPROTEINASE- 9 PROTEIN IN HUMAN TEARS) CPT code: 83516 Indications and Limitations of Coverage and/or Medical Necessity:

Argus considers Inflammadry testing experimental, investigational, and not a covered service for the diagnosis of dry eyes in patients with mild DED (dry eye disease) clinical findings.

For patients with severe DED clinical findings, the MMP-9 test is considered reasonable because the presence or absence of inflammation related to DED may impact the subsequent treatment.

Source: CMS LCD# L36232 Diagnostic Evaluation and Medical Management of Moderate-Severe Dry Eye Disease (DED), November 2015

FLUORESCEIN ANGIOGRAPHY CPT code: 92235 Indications and Limitations of Coverage and/or Medical Necessity:

Covered conditions may include: Retinal vascular disease (H31.3xx, H31.4xx, H34.xxx, H35.0xx, H35.1xx, H35.2x, H35.6x, H35.7xx,

H35.8x) Central serous retinopathy (H35.71x) Retinal vascular occlusions (H34.xxx) Clinically significant diabetic macular edema (E10.3x1, E11.3x1) Cystoid macular edema (H35.35x) Epiretinal membrane – suspicion of other macular disease present (i.e. blood, lipids or edema)

(H35.37x) Exudative macular degeneration or a suspicion thereof (H35.32) Moderate to severe non-proliferative diabetic retinopathy (E10.33x, E10.34x, E11.33x,

E11.34x) Proliferative diabetic retinopathy (E10.35x, E11.35x) Suspected choroidal neovascularization (H35.05x) Active chorioretinitis (H30.xxx) Suspected or established retinal or choroidal neoplasms (D48.7)

Sources: CMS LCD# L33997 Fluorescein Angiography, October 2015 Age-Related Macular Degeneration, American Academy of Ophthalmology Preferred Practice Pattern, 2008 Diabetic Retinopathy, American Academy of Ophthalmology Preferred Practice Pattern, 2008

FUNDUS PHOTOGRAPHY CPT code: 92250 Indications and Limitations of Coverage and/or Medical Necessity:

Covered conditions may include: Baseline study of choroidal nevus (changes may indicate repeat) Baseline study of choroidal neoplasm (changes may indicate repeat) CMV retinitis or other retinitis with active borders Baseline study of glaucoma or glaucoma suspect (changes may indicate repeat)


Active histoplasmosis Active toxoplasmosis Active choroiditis Active chorioretinitis Papilledema, optic atrophy

To request pre-authorization for an unlisted condition, submit clinical notes and a narrative for review.

Sources: CMS IO Manual 100-08, Section 13.5.1 Medicare LCD# L33670 Fundus Photography Primary Open Angle Glaucoma, American Academy of Ophthalmology Preferred Practice Pattern, 2006 Diabetic Retinopathy, American Academy of Ophthalmology Preferred Practice Pattern, 2008

INDOCYANINE GREEN ANGIOGRAPHY CPT code: 92240 Indications and Limitations of Coverage and/or Medical Necessity:

Covered conditions may include: Hemorrhage or hemorrhagic retinal pigment epithelium (RPE) Presence of subretinal fluid Choroidal neovascularization Serous detachment of RPE Exudative macular degeneration Subretinal hemorrhage

Documentation should support the need and frequency for the procedure.

Sources: Age-Related Macular Degeneration, American Academy of Ophthalmology Preferred Practice Pattern, 2008 CMS LCD# L33911 Indocyanine Green Angiography, October 2015

SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (SCODI) CPT codes: 92132-92134 Indications and Limitations of Coverage and/or Medical Necessity: Within the code range there are several different tests described as scanning computerized ophthalmic diagnostic imaging or SCODI. These tests are employed to assess the anterior and posterior segments of the eye.

92132 Anterior Segment - Covered conditions may include: Identification of structural abnormalities blocked by an opaque cornea No coverage related to refractive surgery

92133 Posterior Segment, Optic Nerve - Covered conditions may include: Papilledema, optic atrophy Glaucoma or glaucoma suspect May be used in lieu of fundus photos

92134 Posterior Segment, Retina - Covered conditions may include: Assessment of active retinal treatment Presence of new bleeding or lesion on retinal examination Guidance in treatment for intravitreal injections Ocular neoplasm


Retinoschisis Choroiditis Chorioretinitis

Sources: Primary Open Angle Glaucoma, American Academy of Ophthalmology Preferred Practice Pattern, 2008 Primary Open Angle Glaucoma Suspect, American Academy of Ophthalmology Preferred Practice Pattern, 2006 CMS LCD# L33751 Scanning Computerized Ophthalmic Diagnostic Imaging, October 2015

VISUAL FIELD TESTING CPT codes: 92081-92083 Indications and Limitations of Coverage and/or Medical Necessity:

Covered conditions may include: Progressive optic neuropathy with loss of visual acuity and/or color vision, of unknown etiology Optic neuritis Optic neuropathy (anterior ischemic) for the purpose of diagnosis Inflammation or eyelid disorders affecting the visual field Recent intracranial hemorrhage, mass or recent measurement of increased intracranial pressure with or without

visual symptoms Recent documented occlusion or stenosis of cerebral and precerebral arteries, a recently diagnosed transient

cerebral ischemia or giant cell arteritis Initial workup for buphthalmos, congenital anomalies of the posterior segment, or congenital ptosis Inflammation or disorder of the orbit which affects the visual field Significant eye injury Unexplained visual loss described as “trouble seeing” or “vision going in and out” Pale or swollen optic nerve documented by recent eye exam Functional limitations (i.e. family may report patient bumping into things) Unexplained central vision loss resulting in acuity measured at or below 20/70. Repeated visual field testing is

not indicated unless documented visual changes or to evaluate surgical results Repeat visual fields for pre-surgical patients undergoing surgery on upper eyelids and brow (CMS LCD# L34028

- FL). Initial taped and untaped test must be done on the same day. To monitor effects of high-risk medication (i.e. Plaquenil) Support glaucoma diagnosis Follow status of glaucoma disease

Repeat and subsequent visual fields are not reimbursed for poor reliability. Levels and frequency should be supported by documentation and severity/type of the patient’s condition. Medical necessity does not support visual fields for patients with a previously diagnosed retinal detachment or an established diagnosis of cataract unless other symptoms support the test. Visual fields are also not indicated in patients that are pre-cataract surgery and do not have glaucoma or are not glaucoma suspects. Medical record documentation: Medical necessity should be clearly indicated in the patient chart. Results of the testing should be available for review. Sources: Primary Open Angle Glaucoma, American Academy of Ophthalmology Preferred Practice Pattern Primary Open Angle Glaucoma Suspect, American Academy of Ophthalmology Preferred Practice Pattern


Comprehensive Adult Eye Examination, American Academy of Ophthalmology Preferred Practice Pattern CMS LCD# L33766 Visual Field Examinations, October 2015

PHARMACEUTICALS IN OPHTHALMOLOGY Argus does not pay for pharmaceuticals as they are excluded in our contracts with the health plans. Argus does provide oversight regarding the use of the following pharmaceuticals on behalf of the health plans. Botulinum toxins: Used to influence neuromuscular transmission for certain conditions. Four preparations are approved for ophthalmic use:

J0585 onabotulinumtoxin A (Botox®) J0586 abobotulinumtoxin A (Dysport®) J0587 rimabotulinumtoxin B (Myobloc™) Q2040 incobotulinumtoxin A(Xeomin®)

Covered conditions may include:

Blepharospasm Certain types of strabismus Compressive optic neuropathy Orofacial dyskinesia Spastic entropion Thyroid eye disease with extraocular dysfunction

*Cosmetic or aesthetic use of any type is not covered. Sources:

- CMS LCD# L33274 Treatment with Botulinum Toxins A & B, October 2015 - Dulton Jonathan, Fowler Amy: “Botulinum Toxin in Ophthalmology”, Survey of Ophthalmology January 2007

vol. 52 (1); p. 13-31

AVASTIN® (BEVACIZUMAB) CPT code: J9035, J3490, J3590 No pre-authorization is required for the usage of intravitreal Avastin. It is the health plan’s preferred drug for initial treatment of exudative macular degeneration if not contraindicated. Argus does not intend to dictate if or when a change to a different medication should be done, but appropriate documentation of a failed response to current treatment with Avastin after a reasonable length of time before changing medication i.e. in chart notes or in the form of a narrative) is required. A single intravitreal dose is 1.25 mg/0.05 mL. Covered conditions may include: Proliferative diabetic retinopathy with macular edema Retinal neovascularization NOS Other nondiabetic proliferative retinopathy Central retinal vein occlusion Venous tributary (branch) occlusion of retina Exudative senile macular degeneration of retina Cystoid macular degeneration of retina Retinal edema Rubeosis iridis


Glaucoma associated with vascular disorders of eye Source:

ICD-10-CM for Physicians, 2015

EYLEA® (AFLIBERCEPT) CPT code: J0178 Eylea is a vascular endothelial growth factor inhibitor for neovascular (wet) age-related macular degeneration and macular edema following retinal vein occlusion or associated with diabetic retinopathy. The recommended intravitreal dose of Eylea is 2 mg/0.05 mL every 4-8 weeks as needed. Pre-authorization is required for each time the drug is administered and each pre-authorization is good for one visit. Avastin is the health plan’s preferred drug for initial treatment of exudative macular degeneration, if not contraindicated. Argus does not intend to dictate if or when a change to a different medication should be done, but appropriate documentation of a failed response to current treatment with Avastin after a reasonable length of time before changing medication (i.e. in chart notes or in the form of a narrative) is required.

Covered conditions may include: Neovascular (wet) age-related macular degeneration (AMD) Macular edema following retinal vein occlusion (RVO) Diabetic macular edema (DME)

A single intravitreal injection will be considered medically necessary for the above conditions when all of the following criteria are met: Patient must not have active or suspected ocular or periocular infections Patient must not have active intraocular inflammation Patient must not have known hypersensitivity to aflibercept

JETREA® (OCRIPLASMIN) CPT Code: J7312 Jetrea is a proteolytic enzyme indicated for the treatment of symptomatic vitreomacular adhesion (ICD-10 code H43.82x). The recommended dose is 0.125 mg (0.1 mL of the diluted solution) and is administered by intravitreal injection to the affected eye. Pre-authorization is required prior to one time only use. A single injection will be considered medically necessary when all of the following criteria are met: Optical coherence tomography (OCT) demonstrates vitreous adhesion within 6 mm of the fovea and

a corresponding elevation of the posterior vitreous cortex. The patient’s best corrected visual acuity is 20/25 or less in the affected eye The patient does not have any of the following concomitant conditions:

o proliferative diabetic retinopathy o retinal vascular occlusion o macular hole greater than 400 µm in diameter o epiretinal membrane o vitreous opacification o neovascular age-related macular degeneration o high myopia o aphakia o lenticular or zonular instability o poorly controlled glaucoma


The patient must also not have a history of any of the following: o retinal detachment o prior vitrectomy in the affected eye o prior laser photocoagulation of the macula in affected eye o prior treatment with ocular surgery, intravitreal injection, or retinal laser

photocoagulation in the past 3 months.

LUCENTIS® (RANIBIZUMAB) CPT code: J2778 Pre-authorization is required for each time the drug is administered, and each pre-authorization is good for one visit. Avastin is the health plan’s preferred drug for initial treatment of exudative macular degeneration, if not contraindicated.

Argus does not intend to dictate if or when a change to a different medication should be done, but appropriate documentation of a failed response to current treatment with Avastin after a reasonable length of time before changing medication (i.e. in chart notes or in the form of a narrative) is required.

Lucentis is a VEGF inhibitor and is indicated for treatment for the following conditions with the associated dosage on a monthly or as needed basis. 1 unit = 0.1 mg (0.01 mL) Neovascular (wet) macular degeneration (5 units) Macular edema following retinal vein occlusion (RVO) (5 units) Diabetic macular edema (3 units) Diabetic retinopathy in patients with diabetic macular edema (3 units)

Covered Conditions may include:

Diabetic macular edema Central retinal vein occlusion Venous tributary (branch) occlusion of retina Exudative senile macular degeneration of retina Cystoid macular degeneration of retina Retinal edema

MACUGEN® (PEGAPTANIB SODIUM) CPT code: J0585

Covered conditions may include: Neovascular (wet) age-related macular degeneration

A single intravitreal dose is 0.3 mg/90 µL administered no more frequently than every six weeks.

Contraindications Ocular or periocular infection Hypersensitivity

Source:

Age-Related Macular Degeneration, American Academy of Ophthalmology Preferred Practice Pattern

OZURDEX® (DEXAMETHASONE INTRAVITREAL IMPLANT) CPT code: J7312


Ozurdex (0.7 mg) is a corticosteroid intravitreal implant containing dexamethasone in the Novadur solid polymer drug delivery system. Ozurdex is indicated for the treatment of the following conditions:

Macular edema secondary to retinal vein occlusion (RVO) Non-infectious uveitis affecting the posterior segment of the eye Diabetic macular edema

Pre-authorization is required for each time treatment is administered. A single injection will be considered medically necessary for the above conditions when all of the following criteria are met:

1. The patient does not have active or suspected ocular/periocular infections including most viral diseases of the cornea and conjunctiva.

2. The patient does not have glaucoma with a cup to disc ratio greater than 0.8 3. The patient does not have a torn or ruptured posterior lens capsule

RETISERT AND ILLUVIEN (FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT) CPT Code: J7313 Illuvian is an intravitreal implant containing 0.19 mg fluocinolone acetonide, and is designed to release fluocinolone acetonide at an initial rate of 0.25µg/day for 36 months. Illuvian is indicated for the treatment of the following conditions:

Chronic non-infectious uveitis affecting the posterior segment of the eye Diabetic macular edema in persons who have been previously treated with a course of

corticosteroids and did not have a clinically significant rise in intraocular pressure. Pre-authorization is required for each time treatment is administered. A single injection will be considered medically necessary for the above conditions when all of the following criteria are met:

1. The patient does not have active or suspected ocular/periocular infections including most viral diseases of the cornea and conjunctiva.

2. The patient does not have glaucoma with a cup to disc ratio greater than 0.8 3. There is an inadequate or anticipated extended need for long term treatment with a

corticosteroid such as Ozurdex. 4. There is no history of ocular hypertension in response to steroid treatment.

VISUDYNE® (VERTEPORFIN): WITH PHOTODYNAMIC THERAPY (PDT) CPT code: J3396

Covered conditions may include: Neovascular (wet) age-related macular degeneration (new or recurrent) with sub foveal CNV and both

of the following conditions: o Classic component > 50% of lesion o Entire lesion is < 5400 microns at the largest diameter

Neovascular AMD with occult CNV with one of the following: o Best corrected visual acuity < 20/50 o CNV < 4 disc areas in size when the acuity is > 20/50

The use of verteporfin to treat juxtafoveal or extrafoveal lesions is not covered.

Sources:


- Age-Related Macular Degeneration, American Academy of Ophthalmology Preferred Practice Pattern, November 2008

- CMS NCD#: 100-3 Ocular Photodynamic Therapy (OPT) with Verteporfin (80.3) for ARMD, April 2004

LASER IRIDOTOMY CPT code: 66761 Indications and Limitations of Coverage and/or Medical Necessity:

Angle closed or at a high or significant risk of closure Findings/patient history show attacks of narrow angle glaucoma

Sources: Primary Angle Closure Glaucoma, American Academy of Ophthalmology Preferred Practice Pattern, 2005 CMS, LCD# L33914 “Iridotomy by Laser Surgery”, October 2015

LASER TRABECULOPLASTY CPT code: 65855 Indications and Limitations of Coverage and/or Medical Necessity:

Open angle glaucoma diagnosis with confirmed progressive optic nerve damage Sources: Primary Open Angle Glaucoma, American Academy of Ophthalmology, Preferred Practice Pattern, 2006 CMS, LCD# L33917 “Laser Trabeculoplasty” October 2015

LASER TRABECULECTOMY CPT code: 65850 Indications and Limitations of Coverage and/or Medical Necessity:

Documented progressive glaucomatous damage even with topical and/or laser treatment Documented patient non-compliance or poor compliance with a medical regimen Uncontrolled high intraocular pressure Documented deficient compliance with follow-up care Poor response or outcomes from standard therapy in the other eye (i.e. topical)

Source: Primary Open Angle Glaucoma, American Academy of Ophthalmology, Preferred Practice Pattern, 2006 LID LESION EXCISION CPT Codes: 67840-67850 and 11440-11446 Indications and Limitations of Coverage and/or Medical Necessity:

Lid margin lesions that are causing: • Excessive irritation • Bleeding • Vision obscuration • Suspected malignancy


No coverage for cosmetic removal of benign eyelid lesions of any kind.

Medicaid Additional Exam & Material Benefits Medicaid members may be covered for additional services if the following conditions apply:

Services that are determined medically necessary and do not duplicate another provider’s service.

Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;

Be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment and not in excess of the recipient’s needs;

Be consistent with generally accepted professional standards as determined by the Medicaid program and not be experimental or investigational;

Reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide and

Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.

Additional eyeglasses and lenses are covered as follows:

For children (age 20 and younger) a replacement pair of eyeglasses may be provided o if medically necessary as defined below o if the member cannot tolerate using multifocal lenses, the provider may dispense a

second pair, (i.e. one pair for distance, one pair for reading) Additional pairs of eyeglasses must be approved by Argus

For adults (age 21 and older) eyeglass frames are limited to one (1) pair every two years from date of service. Lenses may be provided every year. Additional lenses are available by authorization only.

All requests for additional services must be pre-authorized and include clinical records showing significant, clinically relevant and sufficient reason for additional eyeglasses, lenses or frames.

Polycarbonate Lenses: Polycarbonate or equivalent (thermoplastic) lens material may be used for the safety of an individual recipient meeting a specific criterion: The recipient is monocular; the corrected sight in the poor eye being 20/50 or worse. The recipient has significant amblyopia. The recipient has had a retinal detachment or is significantly at risk for retinal detachment, e.g.,

lattice degeneration, history of retinal detachment in the family, posterior vitreous detachment, retinal holes.

The recipient has a seizure disorder. The recipient has Marfan’s Syndrome, an ocular prosthesis, or keratoplasty. The recipient is involved in an occupation or physical exercise sport where there is high risk of eye trauma

and the eyes must be protected beyond the usual plastic lens spectacle correction. The condition(s) rendering the recipient eligible for polycarbonate lenses must be sufficiently documented and maintained in the recipient’s medical record.

Medically necessary reasons for a second pair of glasses within the benefit period: Changes in prescription for the following or similar reasons:

• Adie’s tonic syndrome • Astigmatism shift or increase, significant • Cataracts


• Contact lens induced • Diabetes • Keratoconus • Latent hyperopia increase • Myopia progression • Orbital tumor • Paralysis or paresis of accommodation • Post ocular trauma • Post refractive surgery • Post surgical aphakia or pseudophakia • Pterygium • Retinopathy of prematurity • Systemic drug reaction • Treatment with miotics

Damaged frames or lenses • Lenses are significantly scratched (pitted, scarred, chipped, cracked, broken) or

damaged beyond repair • The frame is broken or damaged beyond repair • The frame is too small (outgrown)

Lost eyeglasses –one or more of the following medically necessary replacement criteria must be present:

• The loss is caused by an event directly related to a medical condition such as Down’s syndrome, seizure disorder or mental retardation

• The loss is a result of victimization such as a mugging, beating, robbery, spousal abuse, house fire, nursing home loss, or loss by a third party, e.g. family member, caretaker, nurse or teacher.

• Presence of factors that would endanger life, career, or schooling of the recipient due to uncorrected refractive error, such as cannot pass a driver’s test, cannot function at employment, or cannot function in classroom.

• Presence of related ocular or visual factors whereby not having the glasses may cause one or more of the following to occur:

• Symptoms of hurt, pain, discomfort, irritation, accommodative spasms, headache, or diplopia

• Strabismus or other ocular motility problem • Significant, symptomatic anisometropia or aniseikonia exists and needs

correction • Significant heterophoria and a need for correcting spectacle prism or near

prescription • Central visual acuity is compromised because of a visual field defect • Protection for the good eye is needed in a monocular patient (amblyopia or organic loss

in poorer eye) • Specific learning disability is present and correction is necessary or binocular vision

anomaly is present and a correction is necessary

Note: If only the frame is broken, only the frame may be replaced; if only lenses, then only lenses may be replaced.


All requests for additional benefits must be pre-authorized to assure the requested service or materials meet the state Medicaid benefit requirements. Source: Florida Medicaid Optometric and Visual Services provider handbooks

OCULAR SURFACE RECONSTRUCTION LIMBAL STEM CELL ALLOGRAFT LIMBAL CONJUNCTIVAL AUTOGRAFT CPT CODES: 65781-65782 Indications and Limitations of Coverage and/or Medical Necessity:

Severe ocular surface disease leading to pain and or loss of vision caused by

Inflammatory conditions

Injury

Corneal changes due to congenital conditions

Source:

Kim Joung, Djalilian Ali, Schwartz Gary, Holland Edward: “Ocular Surface Reconstruction; Limbal Stem Cell Transplantation” Ophthalmology Clinical of North America, March 2003, vol 16 (1) p. 67-77

PEDIATRIC EYE CARE Argus encourages the use of community optometrists or ophthalmologists to see pediatric members. The use of pediatric sub-specialists is not indicated for routine eye exams or common childhood eye problems, such as conjunctivitis or blocked tear ducts. Pediatric sub-specialists are not always conveniently located. They are highly specialized and costly. Simple issues can be resolved close-to-home at a nearby optometrist’s or general ophthalmologist’s office. These offices also are more likely to have evening and weekend hours, making them more accessible to children with working parents. A quick assessment by a community eye care provider can give parents peace of mind with either immediate treatment or appropriate referral to a sub-specialist when necessary. Pediatric eye care may require a different set of rules. Additional testing by pediatric sub- specialists may be approved for pediatric members. Pediatric sub-specialists are encouraged to contact our medical director to discuss.

PTERYGIUM EXCISION WITH OR WITHOUT GRAFT CPT Codes: 65426, 65420 Covered conditions may include:

Continued documented growth or related adverse symptoms despite medical treatment Elevated pterygium causing dellen formation Growth involving or impinging on the pupillary axis Irregular astigmatism with reduction in best corrected vision and associated visual symptoms Restriction of eye movement with diplopia

External photos will not be reimbursed unless the following conditions are met: Photos may be prints or slides and submitted with pre-authorization request. Encrypted color


digital images are preferred and should be submitted using a secure e- mail method to protect patient privacy.

Photos must be a close-up and clear view of an undilated eye with patient looking straight ahead (corneal light reflex should be visible)

External ocular photography (CPT 92285) will be paid upon submission of the claim for the surgery if the surgery is authorized. If the surgery is not approved, 92285 will not be reimbursed.

Source:

Hirst Lawrence: “The Treatment of Pterygium”, Survey of Ophthalmology March/April 2003, vol 48 (2) STRABISMUS CORRECTION, ADULT CPT Codes: 67311-67345 Covered conditions may include: Extraocular muscle imbalances that are causing problems with binocular vision and result in functional impairment. Documentation: The following documentation must be submitted:

Original office records addressing the specific signs and symptoms of the visual problems, including the date of onset

Past history of vision problems, including previous eye muscle surgery or orthoptic treatments, and

Pre-operative evaluations that include descriptions of visual function: o Vision with and without glasses o Measurements of muscle imbalance, in prism diopters o Prognosis relative to binocular potential (excluding implied influence on peripheral

visual fields) o Prognosis for fusional potential o Prognosis for stereopsis

Red Flag: The strabismus surgery policy is designed to ensure that patients with eye muscle imbalance whose vision is adversely affected will have their strabismus surgery authorized if there is a reasonable chance that they will experience a functionally significant improvement in binocular vision. Since children with eye muscle imbalance have a high likelihood of improvement with surgery, all patients age 16 or less will have their requests for strabismus surgery authorized without medical director review. Patients who have had binocular vision but who have recently developed double vision due to eye muscle imbalance are also more likely to achieve binocular vision following surgery. Members age 17 and older who have had strabismus for many years without having achieved binocular vision are unlikely to achieve binocular vision with strabismus surgery. A marginal increase in "peripheral vision" that may or may not occur in a member with long-standing strabismus and long-standing loss of binocular vision is not a sufficient reason to authorize strabismus surgery. Sources: Helveston, E., MD. The Value of Strabismus Surgery, Ophthalmic Surgery, May 1990, vol 21, No 5. Ing MR: Early surgical alignment for congenital esotropia. J Pediatric Ophthalmology & Strabismus 1983:

20:11-18. Scott, E.W., et al: 20th Annual Frank Costenbader Lecture-Adult Strabismus, J Pediatric Ophthalmology

Strabismus 1995; 32:348-352. Ticho, BH., Strabismus. Pediatric Clin North Am. 2003; 50 (1): 173-88.


Strabismus in patients over the age of 60 years. Magramm, I., and Schlossman, A. J. Pediatric Ophthalmology Strabismus 1991 Jan- Feb; 28(1) 28-31. Ocular Surgery for the New Millennium. Treatment of Eye Position, Alignment, and Muscle Movement

Problems in the New Millennium. Ophthalmology Clinics of North America, vol 12 Number 4 December, 1999 p 573-580.

Evaluation of Permanent Visual Impairment. Physicians’ Desk Reference for Ophthalmology, ed 27. Montvale, NJ. Medical Economics Company, 1999.

Empire Medicare Services New Jersey. "General Ophthalmological Services." Policy # M- 42. Dated July 9, 2001. Retrieved January 18, 2002. Medicare legal review. September 29, 2003.

Clinical Criteria

The criteria outlined in the Plan’s Provider Office Reference Manual (ORM) are based around procedure codes as defined by CMS. Documentation requests for information regarding treatment using these codes are determined by generally accepted vision standards for review.

These criteria were formulated from information gathered from practicing physicians, CMS clinical articles and guidelines, insurance companies, as well as other vision related organizations. These criteria and policies must meet and satisfy specific state and health plan requirements as well. They are designed as guidelines for review and payment decisions and are not intended to be all-inclusive or absolute. Additional narrative information is appreciated when there may be a special situation. The Plan’s hope is that the enclosed criteria will provide a better understanding of the decision-making process for reviews. The goal focuses on incorporating generally accepted criteria that will be consistent with the CMS, state and health plan requirements, and eye care standards of care. Your feedback and input regarding the constant evolution of these criteria is both essential and welcome. The Plan shares your commitment and belief to provide quality care to patients and we appreciate your participation in the program.

Please remember these are generalized criteria. Services described may not apply and you should check the Plan’s schedule of benefits. In addition, there may be additional program specific criteria regarding treatment. Therefore, it is essential you review the schedule of benefits prior to providing any treatment.

V. Referral Process Please utilize a direct referral process. The Primary Care Optometrist may directly refer a Member to a participating Specialty Ophthalmologist if not located in a capitated area. The Provider or Member may contact an Argus Customer Care Representative or Provider Relations for the Specialists in their area. Specialist Referral Process and Forms The Primary Care provider will provide most of the treatment a Member needs. However, when a Primary Care provider determines that a Member needs services outside the scope of their capabilities, the provider will submit a Specialist Referral form to Argus on the Member’s behalf. The referral form must contain a clear


explanation or narrative. Argus will determine if the treatment outlined in the referral is necessary, depending on the documentation provided by the primary care provider and the authorization guidelines. Once it is determined that the treatment is necessary, an Argus Care Coordinator will locate and contact an in- network Specialist and inform the office of the pending member’s name and referral purpose. The Argus Care Coordinator will then contact the Member and advise them of the Specialist to contact for initial consultation related to the referred procedures. After the Member is seen at the Specialist’s office, the Specialist must submit the diagnosis, treatment plan recommendation and the necessary documentation to Argus for pre-authorization. Once approved, the Member’s treatment will be covered.

Emergency Referral Requests

Emergency care is treatment that must be rendered in order to alleviate pain and/or prevent worsening of the condition that would be caused by delay. The Plan has established an “Emergency” request line to expedite the receipt and processing of all emergency requests and to assure that emergency care is not delayed. Please submit referral requests to [email protected]. Standard referrals are processed within 14 days and urgent requests are processed within 72 hours.

When submitting a (non-hospital) “emergency” request for referral, please assure that the patient’s emergency condition and treatment rendered meet the definition of emergency and that the palliative care rendered is clearly stated on the request form. By definition and statutory requirement, all emergency services and care are required to be rendered immediately, within the same day. If this is not the case, please do not fax non-emergent requests to the Plan, indicating they are emergent, in order to obtain a more expedient response. Inappropriate Referrals

The Primary Care provider is responsible for ensuring that the proper referral guidelines are followed as outlined above. Services inappropriately referred may be determined to be the financial responsibility of the Primary Care provider. The completed referral may be subject to retrospective review which includes clinical review by our Vision Director or licensed vision consultant.

An inappropriate referral is:

a. Specialty referral for services not eligible for referral. b. Specialty referral for services that are basic in nature and did not meet the condition outlined for a

Specialty referral. c. Specialty referral to a non-participating Specialist. d. Specialty referral for non-covered benefits

Provider Web Portal Argus Dental & Vision Plan offers our providers web portal access that allows for: 1. Verifying member eligibility 2. Uploading claims 3. Checking the status of claims and pre-determinations



4. Viewing and downloading of EOBs

Registration

1. Make sure the providers are registered at https://portal.argusdentalvision.com/

2. To register click on 3. Payer Assigned Number will be the capital letter “T” followed by their tax id number no

spaces or dashes. Then complete steps from there.

Member Eligibility

1. Search 2 of the required fields

2. Once completed click search 3. Member Eligibility List will come up to view eligibility for more

information click on “members name” i. *** For vision providers, you do not have to click on the members name,

providers can now click on the “usage’ button. It will allow them to see if a member is eligible for a routine exam as well as materials.

4. To see history click on “View Service History”(Top Left)

Please note that confirmation of eligibility is not a guarantee of payment. If you are having difficulty accessing either the IVR or the website, please contact provider services at 813-280-4800.

When submitting claims

1. Make sure the box that says” Treating same as billing” is checked 2. DO NOT fill out SSN/TIN# or License# 3. Providers MUST set provider preferences before they can submit claims. See below for

instructions.

https://portal.argusdentalvision.com/


Trouble shooting steps to verify on providers profile

1. Make sure they are using the most current version of Internet Explorer (11)

2. Check provider preferences this should be the correct settings

Advise providers to change the first (3) questions to “yes” and then to submit. To check remittance advice Click on Remittance Advice Search


1. Click on “Check or EFT Trace No” 2. To View EOB’s for Checks or EFT’s click on “Expand/Collapse

If you have questions regarding the registration process or functionality issues can be emailed to: [email protected] or you may call 813-280-4800 and speak to a Vision Network Manager for assistance.

VI. Claims Claim Guidelines Please submit all claims on the current version of the HCFA 1500, Argus Provider Portal or electronically via Emdeon. Please see the following required data for claims to be considered “CLEAN”:

Box Description Notes 1a Insured’s ID number Member ID as it appears on their ID card 2 Patient’s name 3 Patients DOB and sex 4 Insured’s name 5 Patient address Number, street, city, state, zip, phone number

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6 Patient relationship to insured 7 Insured’s address Number, street, city, state, zip, phone number 8 Patient status Single, Married, Other, Employed, Student, etc. 10 Patient’s condition related to Auto accident, workers compensation, etc. 11 Insured Policy group Vision Plan Group Name 11a Insured’s DOB and sex 11c Name of other Third Party Payer Vision Plan Name 11d Other health benefit plan 12 Patient signature Patient or authorized person 13 Insured signature Insured or authorized person 14 Date of current illness 17 Name of referring physician 21 Diagnoses Please code to greatest specificity 23 Prior authorization number Use number you receive from Argus here (medical services only)

24a Dates of service 24b Place of service 24d Procedures Use CPT, HCPC’s, Modifiers, PQRS codes 24e Diagnosis pointer Relate to correct diagnoses in box 21 24f Charges Use whole dollars and cents, i.e. $29.95 24g Days or units of service 24j NPI of rendering physician 25 Federal tax ID number 26 Your account number 28 Total charges 31 Signature of physician/supplier Include degree/credentials 32 Facility where services rendered Include name and address 32a NPI of facility 33 Physician/supplier info Name, address, zip and phone number 33a NPI of billing entity

It is the provider’s responsibility to include all applicable information on their claims in order to be processed. Clean claims are paid within thirty (30) days of the receipt of the claim. Missing information will result in the rejection of a claim.

Explanation of Payment (EOP) Each Provider office will receive an EOB report with their remittance. This report documents all patient information submitted on the claim with allowable fee, by date of service for each service rendered

Claims Appeal/Reconsideration Process If appeals are not a delegated function of the Argus contract with the Health Plan, appeals received by Argus are forwarded, by fax or as directed, to the Health Plan within one (1) day of receipt of the appeal. The notification to the Health Plan includes any documentation provided with the notification, including supporting documents, records, Waiver of Liability, and other related information.

If the appeal is a delegated function, the member or provider has sixty (60) days from the processed date in order to appeal a denied claim. The member/provider will need to submit all pertinent information. Upon receipt of the provider’s reconsideration request, Argus will acknowledge receipt via mail to the provider. If the appeal is received after sixty (60) days and the claim was denied in accordance with the plans benefits, exclusions and

Page 40


limitations, then the claim will remain denied and the member/provider will receive a letter of explanation. The member will be issued an Integrated Denial Notice letter. Level 1 appeals: Requests to change a reconsideration decision, an initial utilization review decision, or an

initial claim decision based on medical necessity or experimental/investigational coverage criteria.

Level 2 appeals: Requests to change a Level 1 appeal decision

Dispute Level Doctor/Provider submission timeframe

Argus response timeframe Contacts

Reconsideration Within 60 calendar days of the initial claim decision

Within 30 business days of receiving request.

Within 30 business days of receiving the request if review by a specialty unit is needed

Call: 877-864-0625

Write: See mailing address below

Email: [email protected]

Submit online: Argus web portal provider website.

Level 1 and Level 2 appeals

Within 60 calendar days of the previous decision.

Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information.

Call: 877-864-0625

Write: Argus Dental Vision 4010 State Street,

Tampa, FL 33609

Claim Submission Argus receives vision claims in the following formats:

Electronic claims via Argus Dental & Vision web portal Electronic submission via your clearinghouse-( we refer to Emdeon earlier PAGE 72-can the

provider use any clearinghouse, I see below a clarification, suggest the same on PAGE 72) HIPAA Compliant 837D File Submission on ADA claim form

Argus utilizes claims submissions and information to collect encounter data. Electronic Attachments Argus accepts medical records –IS THIS TRUE? electronically via Fast Attach™ for review requests. The Plan, in conjunction with National Electronic Attachment, LLC (NEA), and DXC Data Exchange allows Participating Providers the opportunity to submit all claims electronically, including those that require attachments. This program allows transmissions via secure internet lines for radiographs, periodontal charts, intraoral pictures, narratives and EOBs. It is compatible with most claims clearinghouses or practice management systems.

Electronic Claim Submission via Clearinghouse Argus accepts electronic claims through most clearinghouses. You can contact your software vendor and make certain that they have a relationship with Emdeon or Smart Data and have Argus Dental & Vision listed as a payer. Your software vendor will be able to provide you with any information you may need for electronic submission. Argus Dental’s payer ID is ARGUS (all in capital letters).

NPI Requirements for Submission of Electronic Claims

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When submitting claims to the Plan you must submit all forms of NPI and TIN properly and in their entirety for claims to be accepted and processed accurately. PLEASE NOTE: If you registered as part of a group, your claims must be submitted with the NPI number for the Group and the NPI number for the Individual. The TIN(s) for each must also be submitted. These numbers are not interchangeable and could cause your claims to be returned to you as noncompliant.

If you are presently submitting claims to the Plan through a clearinghouse or through a direct integration, you will need to review your integration to ensure that it is in compliance with the revised HIPAA compliant 837D 5010 format.

Paper Claim Submission Paper claims must be submitted on a HCFA 1500 claim Form or other forms approved in advance by the Plan. All information included on the claim must be legible. The member’s name, identification number (on the member ID card) provided by the plans and date of birth must be listed on all claims submitted. Please do not submit the member SSN in place of the member identification. PLEASE NOTE: If the member identification number is missing or miscoded on the claim form, the patient cannot be identified. These situations may result in claims rejections and delay in claim processing.

The paper claim must contain: • Legible provider signature • Provider and office location information clearly identified • Provider’s signature alone is insufficient for identification of the provider • Typed practice name or the Plan’s Provider identification number

The paper claim form must contain a valid provider NPI (National Provider Identification) number. In the event of not having this box on the claim form, the NPI must still be included on the form. The HCFA 1500 claim form only supplies 2 fields to enter NPI. On paper claims, the Type 2 NPI identifies the payee, and may be submitted in conjunction with a Type 1 NPI to identify the eye care professional who provided the treatment. For example, on a standard HCFA 1500 Claim Form, the treating physician’s NPI is entered in field 54 and the billing entity’s NPI is entered in field 49. The date of service must be provided on the claim form for each service line submitted. Eye Care Professionals are to use approved ICD-10 codes as published by CMS or as defined in the schedule of benefits. PLEASE NOTE: There is a $2.00 processing fee per paper claim. Claim Appeal for Timely Filing Explanations of payment from other carriers are acceptable as proof of timely filing. Reports or printouts from practice management systems are not accepted as proof of timely filing. If unusual circumstances exist, please document and submit an appeal.

Claims should be mailed to the following address: New Claims:

Argus Dental and Vision Attn: Claims PO Box 211276


Eagan, MN 55121

Appeals are mailed to: Argus Dental & Vision, Inc. Attn: Claims 4010 W. State Street Tampa, FL 33609

Coordination of Benefits (COB) When the Plan is the secondary insurance carrier, a copy of the primary carrier's Explanation of Benefits (EOB) must be submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a primary carrier's payment meets, or exceeds a Provider's contracted rate or fee schedule, the Plan will consider the claim paid in full and no further payment will be made on the claim in accordance with regulatory requirements, the Plan performs routine and focused audits, to evidence the Plan’s commitment to compliance with all applicable guidelines, law and regulations.

Filing Limits Each Provider contract specifies a specific timeframe after the date of service for when a claim must be submitted to the Plan. Any claim submitted beyond the timely filing limit specified in the contract will be denied for "untimely filing." If a claim is denied for "untimely filing," the Provider cannot balance bill the Member. If the Plan is the secondary carrier, the timely filing limit begins with the date of payment or denial from the primary carrier.

Audit of Claims In accordance with regulatory requirements, the Plan performs routine and focused audits, to evidence the Plan’s commitment to compliance with all applicable guidelines, law and regulations. Plan Participation Argus believes in the full-participation of all eye care providers in the care of our members. However, due to the arrangements we have in certain service areas, not all contracted and credentialed Argus providers may participate on all contracted health plan networks. If you have any questions about your participation status with a certain health plan, please contact your provider relations team. This is an important component to making sure you are reimbursed appropriately for services provided.

Plan Termination If you would like to terminate your participation with Argus’ routine or medical/surgical plans, please notify us. We require a termination letter in writing giving a 90-day term notice. This will allow Argus to recruit and credential another provider to replace your practice on the plan network. If you wish to terminate your participation with Argus Dental & Vision, Inc. In turn, Argus will provide you with a confirmation notice outlining the termination timeline under which your practice is required to continue to see members under the terms of your provider agreement.

Please feel free to contact Provider Relations if you have any questions or concerns and we will do our best to provide an expedient, comprehensive response. We appreciate the excellent care and service you provide to our mutual patients and hope to provide excellent care and service to you and your staff.

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VII. Professional Standards Argus Members make a decision to be treated in your office based on your professional reputation, as well as the location and appearance of your office. Therefore, it is important to you and Argus that decisions regarding treatment to be rendered are always made in the best interest of the patient. While it is not expected that Argus Members should be given preference over other patients, they must be accorded the same appointment availability as all other patients.

Pain Management Pain assessment and management is an integral component of care. Inadequately managed pain can lead to adverse physical and psychological outcomes for patients and their families. Argus requires providers to promptly address and manage patient pain. Assessment of pain is a critical step to providing good pain management to our members.

The management of pain in optometry and ophthalmology encompasses a number of procedural issues, including the delivery of anesthetic and the management of post procedural pain, as well as pain diagnosis, management strategies for conditions that cause pain, and the management of pain in special populations.

The assessment parameters should be explicitly directed by providers through policies and procedures to meet the patient’s needs. Pain should be reassessed after each intervention to evaluate the effect and determine whether modification is needed. Argus expects all providers to practice and follow recommended pain management guidelines, including but not limited to:

• Recognize and treat pain promptly.

• Involve patients and families in pain management plan.

• Improve treatment patterns.

• Reassess and adjust pain management plan as needed.

• Monitor processes and outcomes of pain management.

When Argus performs clinical record evaluations of its providers, Argus will review a number of patient records to ensure that providers are assessing and managing pain properly.

Provider Roles and Responsibilities Providers who participate in Argus have responsibilities, including but not limited to:

• Coordinate with applicable state agencies for any members receiving service or under conservatorship from the Department of Children and Families.


• Provide covered services to members with Argus coverage.

• Provide timely covered services to members at all times.

• Abide by and cooperate with the policies, rules, procedures, programs, activities and guidelines contained in your Provider Agreement.

• Accept Argus payment, plus any applicable member copayment, as payment-in-full for covered services.

• Adhere to guidelines for usage of all electronic self-service tools.

• Comply fully with Argus’ Quality Improvement, Utilization Management, Integrated Care Management and Audit Programs.

• Comply with all applicable training requirements, including training for Fraud, Waste and Abuse, as required by CMS.

• Promptly notify Argus of claims processing payment or encounter data reporting errors.

• Maintain all records required by law regarding services rendered for the applicable period of time, making such records and other information available to Argus or any appropriate government entity.

• Treat and handle all individually identifiable health information as confidential in accordance with all laws and regulations, including HIPAA-AS and HITECH requirements.

• Immediately notifying Argus of adverse actions against license or accreditation status.

• Comply with all applicable federal, state, and local laws and regulations.

• Maintain liability insurance in the amount required by the terms of the Provider Agreement.

• Notify Argus of the intent to terminate the Provider Agreement as a participating provider within the timeframe specified in the Provider Agreement.

• If the Provider Agreement is terminated:

a. Continue to provide services to members who are receiving inpatient services until they are appropriately discharged and/or the specific episode of care is completed.

b. Accept payment at rates in effect under the Agreement immediately prior to termination.


• Verify eligibility immediately prior to rendering service.

• Obtain signed consents prior to rendering service.

• Obtain prior authorization for applicable services.

• Maintain any hospital privileges when hospital privileges are required for the delivery of the covered service.

• Maintain all medical and Medicaid-related member records and communications for a period of ten (10) years according to legal, regulatory and contractual rules of confidentiality and privacy.

• Provide prompt access to records for review, survey or study if needed.

• Cooperate fully in any investigation or review by Argus Dental & Vision, Inc., Agency, Medicaid Program Integrity (MPI), Medicaid Fraud Control Unit, Office of the Attorney General (MFCU), or other state or federal entity and in any subsequent legal action that may result from such an audit, investigation or review.

• When presenting a claim for payment to Argus, the network provider is indicating an understanding that the provider has an affirmative duty to supervise the provision of, and be responsible for, the covered services claimed to have been provided, to supervise and be responsible for preparation and submission of the claim, and to present a claim that is true and accurate and that is for Argus covered services that: a. Have actually been furnished to the recipient by the provider prior to submitting the claim. b. Are medically necessary.

• Report known or suspected child, elder or domestic abuse to local law authorities and have established procedures for these cases.

• Provide encounter data accepted by the Florida Medicaid Management Information System (FMMIS), as either actively enrolled Medicaid providers or as Argus registered providers and/or the State’s encounter data warehouse.

• Inform members of the availability of Argus’ interpreter services and encourage their use.

• Notify Argus of any changes in business ownership, business location, legal or government action, or any other situation affecting or impairing the ability to carry out duties and obligations under the Argus Dental & Vision, Inc. Network Provider Agreement.

• Maintain oversight of non-physician practitioners as mandated by state and federal law.


• Post or display a copy of the summary of Florida’s Patient’s Bill of Rights and Responsibilities (in accordance with s. 381-026, F.S.) and have a complete copy available upon member request at each of the provider’s offices.

Access

You are required to comply with Argus’ rules for reasonable access to medical records during the agreed upon term and upon termination allowing:

Argus representatives or their delegates Member’s subsequent provider(s); or Any authorized third party.

For a maintenance period from the last date of service as required by state law.

Provider Prohibited Activities

Argus providers are prohibited from the following activities:

• Discriminating against any member on the basis of race, color, religion, sex, national origin, age, health status, participation in any governmental program, source of payment, marital status, sexual orientation or physical or mental handicap

• Segregating members from other patients (applies to services, supplies, equipment)

• Billing members for covered services including disputed amounts

• Refusing to furnish a member with a covered Medicaid service solely because the member’s eligibility has not yet transmitted to Florida Medicaid Management Information System (FMMIS) when the member possesses one form of acceptable proof of eligibility.

• Unbundling services that would otherwise be grouped together as a single line item

The following sections discuss the professional standards that Argus expects of all providers participating in Argus Plans:

a) Record Keeping – the Patient Record

b) Sterilization and Infection Control

c) Medical Emergencies

Record Keeping – the Patient Record Review and analysis of medical records is essential for the assessment of the nature of the appropriateness of the care delivered to Argus patients. It should be noted that research data related to malpractice claims against providers indicates that lack of adequate record keeping is the major reason for adverse decisions.


Function of Provider’s Records

1. The primary function is to accurately and clearly document the diagnosis and course of a patient’s history, status, needs and treatment. An appropriate record provides the differential diagnosis, treatment planning and eventual care in clear language and a sequential manner so that anyone reading the record would have an apparent understanding of the patient’s existing condition, related medical factors, proposed and accepted treatment plans, subsequent treatment and a projected outcome or result.

2. The medical record is a means of communication among the treating provider, patients, other health care providers, consultants, and subsequent plan administrators so that all treatment for any particular patient may be accurately recreated.

3. The record is an official document. It will assist in protecting the interests and responsibilities of both the patient and his/her providers.

4. The record serves as a basis for analysis and evaluation of appropriateness of care rendered to a patient in any post-treatment or peer review situation. Characteristics of Providers Records

1. An acceptable record should be logical, sequential, clear, concise, and accurate and include all the necessary information to make an appropriate diagnosis, explain ongoing and subsequent treatment, and establish follow-up/recall care. It should document all missed and cancelled appointments and reasons, emergency treatment, referral to specialist, interfacing with other health care professionals, as well as any patient concerns and/or complaints.

2. The segments of the record should be interdependent and interrelated so as to present an accurate and timely statement of all the facts and occurrences which took place during treatments.

3. Any errors made in the record should only be corrected by drawing a single, thin line through the error with the record correction noted as nearby as possible. The writer is to include their initials near the corrected documentation error. Never block out any previous entry so it becomes unreadable. All entries should only be with a pen utilizing a color reproducible by simple copying means.

4. A complete medical history is required and must be periodically updated upon the patient’s return visits. Organization of Medical Records

1. The record must have areas for documentation of the following information:

• Registration data including a complete health history.

• Medical alert predominantly displayed inside chart jacket.

• Initial examination data.

• Radiographs.


• Eye status.

• Treatment plan/Alternative treatment plan.

• Progress notes to include diagnosis, preventive services, treatment rendered, outcome of treatment rendered that date of service and medical consultations.

• Miscellaneous items (correspondence, referrals, and clinical laboratory reports).

2. The design of the record must provide the capability or periodic update, without the loss of documentation of the previous status, of the following information.

• Health history

• Medical alert

• Examination/recall data

• Eye status

• Treatment plan

3. The design of the record must ensure that all permanent components of the record are attached or secured within the record.

4. The design of the record must ensure that all components readily identify the patient, (i.e., patient name, and identification number on each page clearly marked).

5. The organization of the record system must require that individual records be assigned to each patient, allowing records to be easily identified. Content of Medical Record

1. Adequate documentation of registration information which requires entry of these items:

• Patient’s first and last name

• Date of birth

• Sex

• Address

• Telephone number

• Name and contact number of person in case of emergency.

2. An adequate health history that requires documentation of these items:

• Current medical treatment


• Significant past illnesses

• Current medications

• Drug allergies

• Hematologic disorders

• Cardiovascular disorders

• Respiratory disorders.

• Endocrine disorders.

• Communicable diseases.

• Neurologic disorders.

• Signature and date by patient.

• Signature and date by reviewing doctor.

• History of alcohol and/or tobacco usage including smokeless tobacco.

3. An adequate update of health history at subsequent recall examinations which requires documentation of these items:

• Significant changes in health status.

• Current medical treatment.

• Current medications.

• Eye problems/concerns.

• Signature and date by reviewing doctor.

• Health education and wellness promotion

4. A conspicuously placed medical alert inside the chart jacket that documents highly significant conditions from health history. These items are:

• Health problems which contraindicate certain types of treatment.

• Health problems that require precautions or pre-medication prior to treatment.

• Current medications that may contraindicate the use of certain types of drugs or treatments.

• Drug sensitivities.


• Infectious diseases that may endanger personnel or other patients.

5. Adequate documentation of the initial clinical examination which is dated and requires descriptions of findings in these items:

• Blood pressure. (Recommended)

• Head/neck examination.

• Soft tissue examination.

• Periodontal assessment.

• Occlusal classification.

• Dentition charting.

6. Adequate documentation of the patient’s status at subsequent periodic/recall examinations which is dated and includes descriptions of changes/new findings in these items:

• Blood pressure. (Recommended)

• Head/neck examination.

• Soft tissue examination. Periodontal assessment.

• Dentition charting.

7. Radiographs which are:

• Identified by patient name.

• Dated.

• Designated by patient’s left and right side.

• Mounted (if intraoral films)

• Of acceptable diagnostic quality

8. An indication of the patient’s clinical problems/diagnosis.

9. Adequate documentation of the treatment plan (including any alternate treatment options) that specifically describes all the services planned for the patient by entry of these items:

• Procedure

• Localization

10. Adequate documentation of the periodontal status, if necessary, which is dated and includes


charting of the location and severity of these items:

• Periodontal pocket depth.

• Furcation involvement.

• Mobility

• Recession.

• Adequacy of attached gingiva.

• Missing teeth.

11. Adequate documentation of medical consultations within and outside of the practice which requires entry of these items:

• Provider to whom consultation is directed.

• Information/services requested.

• Consultant’s response.

12. Adequate documentation of treatment rendered which requires entry of these items:

• Date of service/procedure.

• Description of service, procedure and observation.

• Type and dosage of anesthetics and medications given or prescribed.

• Localization of procedure/observation. (Tooth #, quadrant etc.)

• Signature of the Provider who rendered the service.

13. Adequate documentation of the specialty care performed by another provider that includes:

• Patient examination

• Treatment plan

• Treatment status

Sterilization and Infection Control All patients and all staff members must be protected from infectious and environmental contaminants. A copy of Argus’ Infection Control Manual is available for download from the Argus website. Listed below are some of the OSHA pertinent requirements:

1. Personnel should scrub with antibacterial soap before all oral procedures.


2. Sterile gloves should be worn.

3. Face and eye protection should be worn by providers and /or staff when indicated

4. Prior to sterilization, all instruments should be thoroughly debrided using chemical/mechanical means such as ultrasonic, baths, etc.

5. All instruments and equipment, including burs, mirrors and matrix bands that can be sterilized should be rendered sterilized after each use.

6. All instruments and equipment that cannot be sterilized, including operating lights, chair switches, hand pieces, cabinet working surfaces and water/air syringes and their tips, should be disinfected using approved techniques after each use.

7. ADA approved sterilization solutions should be utilized.

8. All sterilization equipment present in the office (including backup sterilizers) must be monitored, using process indicators with each load and spore testing on a weekly basis.

9. Handling of sharps and environmental waste, including the disposal of waste and solutions must be in compliance with all applicable federal, state and local laws and regulations

Medical Emergencies The office should be well prepared to deal with a medical emergency through implementation of one or more of the following:

10. The provider and at least one other staff member should have current CPR training.

11. A formal medical emergency plan should be prepared. Staff members should understand their individual responsibilities if the plan needs to be implemented. Emergency phone numbers should be prominently posted including local fire, police and ambulance numbers in addition to 911.

12. Risk-prone patients should be identified in advance by routinely taking and updating a proper medical history for every patient. All providers offices should have a portable source of oxygen with positive demand valve or ambu-bag, blood pressure cuff and stethoscope.

13. A full complement of emergency equipment should be readily available including sphygmomanometer, stethoscope, ambu-bag or positive pressure oxygen source(mobile), emergency drug kit and oral pharyngeal airway

14. The emergency drug kit will be monitored for expiration dates of any drugs included within this kit.

Patient access to emergency provider treatment must be available on a 24-hour/7-day per week basis. Acute conditions must be addressed within 24 hours. You must designate another provider to address emergencies that may arise when you are not available. Usually this is best accomplished by providers designating another mutually agreeable provider participating in the Argus Dental & Vision network. From time to time, Argus staff will call providers after hours to ensure that these guidelines are being met. If it is identified that the plan in place is not adequate, providers will be called to educate on proper


procedures.

While the primary provider must be available and provide treatment within 24 hours, this does not necessarily require that the provider see the patient in the office outside regular hours except in extreme emergencies. If it is necessary to open the office to see the patient outside of the regular office hours, while the treatment rendered may be covered, the office visit may not be covered. If not covered, you may charge the member your UCR fee less any applicable discount, provided the member is advised in advance.

Every patient should be encouraged to return for recall visits as frequently as indicated by his/her individual status. It is important that each provider’s office have active recall procedures in place. The following should be accomplished at each visit.

VIII. Quality Improvement Program The Plan administers a Quality Improvement Program modeled after National Committee for Quality Assurance (NCQA) and AAAHC standards. The NCQA and AAAHC standards are adhered to as the standards apply to vision managed care. The Quality Improvement Program includes but is not limited to:

a. Provider credentialing and re-credentialing b. Discipline and Termination of a participating provider c. Peer Review Process d. Initial Site Reviews e. Provider Record Reviews and Random Chart Audits f. Utilization Management and practice patterns. g. Member and Provider satisfaction surveys h. Complaint Monitoring and Trending i. Quarterly Quality Indicator tracking (i.e. complaint rate, appointment waiting time, access to care,

etc.)

A copy of the Plan’s Quality Improvement Program is available upon request by contacting the Provider Services Department.

Credentialing and Re-credentialing Process: General Information

Argus Dental & Vision’s credentialing process adheres to National Committee for Quality Assurance (NCQA) and AAAHC standards as the guidelines apply to vision. The Plan has the sole right to determine which vision provider (OD or MD) it shall accept and continue as Participating Providers. The purpose of the credentialing policy is to provide a general guide for the acceptance, discipline and termination of Participating Providers. The Plan considers each Provider’s potential contribution to the objective of providing effective and efficient vision services to members of the Plan. Unless otherwise required, providers are re-credentialed at minimum every three (3) years.

There are two major elements to Argus’ Credentialing Process; a) Initial Credentialing and, b) Re- credentialing process.

i. Initial Credentialing – Initial Verification is performed on a prospective level prior to accepting a

provider into the network. Primary source verification is performed to verify or identify the following: Current license and expiration date DEA verification eligibility/licensure


Appropriate certifications Highest education level Current professional liability insurance Malpractice and disciplinary history Medicaid/Medicare sanctions Negative past professional histories

An attestation to the written application is included in the initial verification process and covers items below: Revocation of hospital privileges Lack of drug use Felony conviction Physical and emotional capability to perform vision procedures

ii. Re-credentialing – All credentialed providers must remain in compliance with the initial

credentialing criteria. The re-credentialing process (re)evaluates the practitioners’ qualifications and practice history, in addition to review of member surveys and/or grievance history. All existing providers will be re-credentialed every three (3) years (or more frequently if required by state law). Argus notifies all providers a minimum of three (3) months in advance of their re-credentialing date. The notification will include the required information to be submitted to Argus to complete the re-credentialing process.

Medicaid Provider Eligibility

All providers must be registered with the Medicaid program prior to being enrolled with Argus, and as a condition to being paid for services rendered. If your provider does not have a Medicaid provider number, but would still like to participate in Argus Medicaid programs, please contact us regarding obtaining Medicaid streamline status that will allow you to see Argus patients even though not fully credentialed with Medicaid.

Argus conducts background screening and verifies initial credentialing and re-credentialing criteria for all professional providers that, at a minimum, meet the Agency’s Medicaid participation standards. The criteria include but are not limited to:

1. Current medical licensure pursuant to s. 641.495, F.S.

2. No revocation or suspension of the provider's state license by the Division of Medical Quality Assurance, Department of Health, and the Agency. Disclosure related to ownership and management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106).

3. Proof of the provider's board certification or evidence of medical school graduation, residency and other postgraduate training.

4. Current Drug Enforcement Administration (DEA) certificate and/or State Controlled Substances Registration certificate, as applicable.

5. Evidence of specialty board certification, if applicable.

6. Evidence of the provider’s professional liability insurance coverage or a Financial Responsibility Form.

7. Satisfactory review of any sanctions imposed on the provider by Medicaid or Medicare.


IX. Provider Rights During the credentialing process, every applicant has the right to:

1. Review information contained in their credentialing file. This does not include information collected from references, recommendations, peer-review and other protected information.

2. Providers have the right to be notified and to correct erroneous information if the credentialing information received varies substantially from the information that was submitted on the application. However, variances in information obtained from references, recommendations, peer-review and other protected information are not subject to this notification.

3. Be informed of the status of their application upon request. 4. Receive notification of these rights.

Questions regarding the status of a credentialing application may be directed to Argus Dental & Vision’s Provider Relation Department at [email protected] or 888.779.3566 ext. 175.

Argus is responsible for ensuring that all participating physicians are credentialed and re-credentialed. However, the optometrists/ophthalmologist is responsible to notify his/her Network support office in writing when additions or terminations of eye care associates occur. The optometrists/ophthalmologist is also responsible for notifying Argus in writing of any adverse action with respect to any credentialing and re- credentialing elements noted above. Failure to do so may result in termination of your participation agreement.

Participating eye care provider must meet the requirement standards regarding the office’s physical attributes, practice coverage, patient access, office procedures, patient load, office records and insurance and professional competence and qualifications. These criteria are used in our credentialing and re-credentialing process. Discipline and Termination of Participating Provider A participating provider may be terminated from the network for any misinterpretations made on his/her application or failure to disclose any required information. Other causes of termination include, but not limited to, fraud; failure to comply with the terms of the Provider Agreement or those outlined in the Provider Manual or any other supplementary material provided in writing by Argus; failure to provide requested vision records; failure to cooperate/comply with the grievance and complaint process or resolution, etc. Nothing in this Credentialing Policy limits the Plan’s sole discretion to accept and discipline Participating Providers. No portion of this Credentialing Policy limits the Plan’s right to permit restricted participation by an eye care office or the Plan’s ability to terminate a Provider’s participation in accordance with the Participating Provider’s written agreement, and in accordance with the regulatory requirements and accreditation standards. The Plan has the final decision-making power regarding Network participation and will notify the applicable regulatory bodies and/or health plan clients of all Appeal of Credentialing & Peer Review Committee Recommendations If the Credentialing & Peer Review Committee recommends acceptance with restrictions or the denial of an application, the Committee will offer the applicant an opportunity to appeal the recommendation. The applicant must request a reconsideration/appeal in writing and the request must be received by the Plan within 30 days of the date the Committee gave notice of its decision to the applicant. Appeal of Credentialing & Peer Review Committee Recommendations If the Credentialing & Peer Review Committee recommends acceptance with restrictions or the denial of an application, the Committee will offer the applicant an opportunity to appeal the recommendation. The applicant



must request a reconsideration/appeal in writing and the request must be received by the Plan within 30 days of the date the Committee gave notice of its decision to the applicant. Initial Site/Office Reviews There are two components to the office reviews; prospective review and ongoing review for participating offices. Each type of review highlights essential areas of office management and vision care delivery. During the review (which may not be scheduled,) the following areas will be evaluated: General Information – includes practice name, address, name of principal owner and associates, staffing information, an available copy of Florida’s Patient’s Bill of Rights and Responsibilities, office hours, availability of appointments and method of 24-hour coverage and the name of the covering vision when the eye care provider is not available. Practice History – office provides information regarding malpractice suits, settlements and disciplinary actions, if applicable Office profile – office indicates services they routinely performed i.e. exams, contact lens fittings, optical dispensing etc. Facility Information – includes location, accessibility (including handicapped accessibility,) description of interior office such as the reception area, operatories, lab, proper sanitation and cleanliness, type of sterilization equipment and radiographic equipment. Risk Management – includes review the infection control plan such as personal protective equipment, i.e. gloves and masks, handling of infectious waste disposal, sterilization and disinfection methods, housekeeping plan and training programs for staff, radiographic procedures and steps for safety, occupational hazard control regarding amalgam, nitrous oxide and hazardous chemicals, medical emergency preparedness training and equipment Active Recall System – includes review of procedures for assuring patients are scheduled for recall examinations and follow-up treatment Site Visits Resulting from Receipt of a Complaint and/or Member Dissatisfaction Regarding Office Environment Argus may identify the need for additional site visits upon receipt of member dissatisfaction regarding the provider’s office environment or provision of care.

Argus’ Provider Network Managers (or other Argus representatives) may conduct a full or a focused site visit to address the specific issue(s) raised by members or other providers. Follow-up site visits are conducted on an as needed basis. Medical Records/Chart Reviews As specified in the Provider Agreement, Argus Dental & Vision, Inc. is authorized to conduct reviews of the Plan members’ treatment records. The records are chosen randomly for periodic review. The Chart Review includes assessment of the following, but is not limited to:

• Recording of the medical history, vision history and existing vision conditions • Diagnostic material used


• Radiograph/image evaluation Treatment plans • Timeliness of treatment • Actual care delivered in relation to proposed treatment plan • Recall protocol • Utilization analysis of actual care delivered • The presence of a signed patient financial informed consent form

Participating offices will receive feedback on the outcome of the Facility/Chart Review of the office. This includes suggested areas of improvement as well as identifying areas of non-compliance. When needed, additional follow-up reviews will be scheduled. The on-site review is a component of our QM activities. Offices that have experienced an on-site facility and chart review may be selected to participate in a survey focused on that experience and their perception of the independent optometry or ophthalmology reviewer. Your feedback is critical to our continuous improvement efforts. Utilization Management Program Community Practice Argus Dental & Vision, Inc. has developed a philosophy of Utilization Management that recognizes the fact that there exists, as in all healthcare services, a relationship between the physician’s treatment planning, treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the “community practice patterns” of local eye care professionals and their peers. With this in mind, the Plan’s Utilization Management Program is designed to ensure the fair and appropriate distribution of healthcare dollars as defined by the regionally based community practice patterns of local physicians and their peers.

All utilization management analysis, evaluations and outcomes are related to these patterns. The Plan’s Utilization Management Program acknowledges that there exists a normal individual provider variance within these patterns among a community of eye care professionals and accounts for such variance.

Evaluation The Plan’s Utilization Management Program evaluates claims submissions in such areas as:

Diagnostic and preventive treatment; Patient treatment planning and sequencing; Types of treatment; Treatment outcomes; and Treatment cost effectiveness.

Results Plan’s Utilization Management Programs will help identify those eye care providers whose patterns show significant deviation from the normal practice patterns of the community of their peer physicians. When presented with such information, physicians will implement slight modifications of their diagnostic and treatment processes in order to bring their practices back within the normal range. However, in some isolated instances, it may be necessary to recover reimbursement. Reimbursement of Services Rendered Reimbursement will only occur for services that are clinically necessary for vision care and do not duplicate another provider’s service. “Medically necessary” is defined as services that meet the following conditions:

a. necessary to protect life, prevent significant illness or significant disability or alleviate severe pain;


b. individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury under treatment and not in excess of the patient’s needs;

c. consistent with generally accepted professional eye care standards as determined by the Florida Healthy Kid’s program, and not be experimental or investigational;

d. reflective of the level of service that can be furnished safely and for which no equally effective and more conservative or less costly treatment is available statewide.

Additionally, the services must meet the following criteria:

The services cannot be experimental or investigational; and The services must be furnished in a manner not primarily intended for the convenience of the

recipient, the recipient’s caretaker, or the provider. The fact that a provider has prescribed, recommended or approved care, goods or services does not, in itself, make such care, goods or services clinically necessary for quality vision care or a covered service. Member and Provider Satisfaction Surveys Satisfaction surveys assist in rating perceptions of the Argus network. Responses are of considerable value to Argus and our continued efforts to improve the quality of services provided and experienced by our customers. Feedback is based upon, but not limited to, experiences when participating within the Argus system such as level of satisfaction with the program, interaction with Argus staff, interaction with provider staff, access to care, our system of referrals for specialty services, utilization and the efficiency and accuracy of Argus’ claims system. The surveys are sent to randomly selected providers and members. Argus Dental & Vision, Inc. then tabulates and reviews the results of these surveys on a quarterly basis. The quarterly reports based on the results of these surveys assist in formulating recommendations to maintain, enhance and improve the future satisfaction of both members and providers. Member & Provider Inquiries, Complaints, Grievances & Appeals The Plan adheres to State, Federal, and Plan requirements related to processing inquiries, complaints, grievances and appeals. Enrollees have the right to request continuation of benefits while utilizing the grievance system. Unless otherwise required by Agency entities and the Plan, processes such as inquiries, complaints, grievances and appeals are defined as the following (per the Medicare Managed Care Manual: Chapter 13)

Inquiry: “Any oral or written request to a Medicare health plan, provider or facility, without an expression of dissatisfaction, e.g., a request for information or action by an enrollee. Inquiries are routine questions about benefits and do not automatically invoke the grievance or organization determination process.” Complaint: “Any expression of dissatisfaction...by an enrollee made orally or in writing”, such as waiting times, adequacy of facilities, disrespect towards and enrollee by staff. “It also includes a Plan’s refusal to provide services to which the enrollee believes he or she is entitled. A complaint could be either a grievance or an appeal, or a single complaint could include elements of both. Every complaint must be handled under the appropriate grievance and/or appeal process.” Administrative Complaint – “An expression of dissatisfaction by an ordering provider, either verbal or written, that is non-clinical in nature. For example: complaint is related to claim adjudication; Argus’s recruitment and/or contracting process, adequacy and/or quality of Argus’s network of servicing vision providers, Argus’s medical policy, etc.”


Grievance: “Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken.” A complaint or dispute can be either oral or written. “Grievances may include complaints regarding the timeliness, appropriateness, access to and/or setting of a provided health service, procedure or item.”

Appeal: “Any of the procedures that deal with the review of adverse organization determinations of the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for or approving the services or on any amounts the enrollee must pay for a service.” Complaints/Grievance Staff Argus’ goal is to resolve member inquiries and complaints without having to move to a formal grievance level. If a member or provider has a concern or question regarding care or coverage, s/he should contact Argus through the toll-free Customer Care number at 888.779.3566 or TDD 800.887.8973. A Customer Service Representative is available to answer questions and/or concerns. The representative will try to resolve the problem. If the concern/problem is unable to be resolved then or in a timely manner, a grievance can be filed.

The Plan’s Complaints/Grievance Coordinator receives member inquiries, complaints, grievances and appeals. A member may file a grievance in writing. Written grievances may be sent to:

Argus Dental & Vision, Inc. Grievances and Appeals Department 4010 W. State Street Tampa, FL 33609

If at any time a member needs language assistance in completing forms or following the procedure for filing a grievance, assistance of an interpreter is available. This interpreter service is free of charge. The Complaints/Grievance Coordinator has office hours from Monday through Friday, 8:00am to 5:00pm. The Coordinator investigates the issues, compiles the findings, requests patient records (if applicable), sends the records to the vision consultant for review and determination (if applicable), and obtains a resolution. The appropriate individuals are notified of the resolution (i.e. Plan, Member, and Provider, as applicable). The complaint is closed and maintained on file for tracking and trending purposes. Contracted providers have a right to file an appeal for denied claims (which include the prepayment review process), prior authorizations and/or referral determinations. This can be done by submitting a request for appeal in writing with a narrative and supporting documentation via mail or fax. Administrative Complaints will be research by Provider Relations and will contact other personnel (Argus claims, network contracting, and provider relations personnel, the complainant provider, etc.) for information and assistance as needed. At the end of the research and within 30 business days of receipt of the complaint, Provider Relations will send communication via email to the complainant provider with the resolution of the complaint. The complaint is closed and maintained on file. Medicaid Fair Hearing Process & Medicaid Subscriber Assistance Program (SAP): 1. Medicaid Fair Hearing Members have the right to ask for a Medicaid Fair Hearing at any time during the grievance and appeals process. The member must ask for a Medicaid Fair Hearing within 90 days for the date they get the determination letter

Page 48


from Argus. You may ask for a fair hearing by calling (850) 488-1429 or writing to: MAIL: Department of Children and Families Office of Appeal Hearings Building 5, Room 255 1317 Winewood Boulevard Tallahassee, FL 32399-0700 FAX: (850)487-0662 EMAIL: Appeal [email protected] OR Call Your Local Area Medicaid Office (see table below)

2. Subscriber Assistance Panel (SAP) If the member does not like our appeal decision, the member has one year after the final decision letter to request a review by the Subscriber Assistance Program (SAP). The member must finish the appeal process first. If the member asks for a fair hearing, they cannot have a SAP review. To ask for a SAP review, call (888) 419.3456 (toll- free) or send the request to: Agency for Health Care Administration


Subscriber Assistance Program (SAP) 2727 Mahan Drive, Mail Stop # 45 Tallahassee, FL 32308 The member’s benefits will not stop while the case is reviewed. The benefits will stop if the member is taken out of Medicaid (disenrolled) for any of the reasons. Please note that the member may have to pay for the cost of those benefits if the Medicaid Fair Hearing upholds Argus’ action.

Quarterly Quality Indicator tracking (i.e. complaint rate, appointment waiting time, access to care, etc.) An essential part of QM is the promotion of timely and appropriate eye care. Appropriate access to care can vary by the type of eye care needed. The following appointment availability standards are monitored via the QM program: Emergency Care – patient must have access 24 hours/7 days a week.

o The primary care provider must provide or arrange for 24 hours per day, 7 days per week emergency care coverage. Emergency care is defined as those eye care services needed to relieve pain or prevent worsening of a condition when delaying such care would cause such outcomes.

Urgent Care – must be provided immediately or within 24 hours. o The eye care provider must be available immediately or within 24 hours for urgent care to be

provided. Routine Care-within 4 weeks.

o Most routine care should be appointed within 4 weeks, provided the patient can schedule the next available appointment.

. Access is monitored by regional Provider Relations staff. Periodically, a written inquiry or phone call may be generated by an Argus Network Specialist to obtain information concerning your next available appointment. This information is also recorded at the time of your site assessment review. Member complaints regarding appointment availability are documented and investigated.

X. Compliance Regulatory Requirements The Plan adheres to all state and federal rules and regulations, requirements from the Centers for Medicare & Medicaid Services (CMS) and Agency for Health Care Administration (AHCA), and health plan contract requirements. Health Insurance Portability and Accountability Act (HIPAA) As a Provider, you and your office is required to comply with all aspects and activities of HIPAA and any revisions to HIPAA, including but not limited to, the Health Information Technology for Economic and Clinical Health (HITECH) Act, the American Recovery and Reinvestment Act of 2009 (ARRA), the Florida Information Protection Act (FIPA), the HIPAA Security and Privacy regulations, and the Administrative Simplification provisions.

The Participating Provider Agreement reflects the appropriate HIPAA compliance language evidencing that as an Argus Provider you agree to abide by all federal and state laws regarding the confidentiality and non-disclosure of medical records and other protected health information (PHI).

In order to comply with these regulations, the Provider should do the following, including but not limited


to:

Maintain in accordance with state and federal law adequate eye care /medical, financial and administrative records related to covered eye care services.

Safeguard all information about members according to applicable state and federal laws and regulations. All member information which is provided to the Provider, shall be treated as confidential information and only be transferred in compliance with state and federal regulations.

Neither the Plan nor Provider shall share a member’s confidential information or PHI to any third party, including spouse, family member, friend, etc., without first obtaining the Member’s consent for such disclosure., unless the state and federal regulations allow disclosure in the particular circumstance.

Please contact the Argus Compliance Officer to report any HIPAA issues or concerns or obtain the Plan’s HIPAA policies and procedures at (813) 283-1276 or [email protected].

Links to Online HIPAA Resources The following is a list of online resources that may be helpful: Accredited Standards Committee (ASC X12)

o ASC X12 develops and maintains standards for inter-industry electronic interchange of business transactions

Association for Electronic Health Care Transactions (AFEHCT) o A healthcare association dedicated to promoting the interchange of electronic healthcare

information. Centers for Medicare and Medicaid Services (CMS)

o CMS is the unit within the Department of Health & Human Services that administers the Medicare and Medicaid programs. CMS provides the Electronic Health Care Transactions and Code Sets Model Compliance Plan.

This site is the resource for Medicaid HIPAA information related to the Administrative Simplification Provision in the Patient Protection and Affordable Care Act (ACA) of 2010

Office for Civil Rights (OCR) o OCR is the office within the Department of Health and Human Services responsible for

protecting fundamental nondiscrimination and health information privacy rights. United States Department of Health & Human Services (HHS)

This site is a resource for the Notice of Proposed Rule Making, rules and other information about HIPAA.

Washington Publishing Company (WPC) o WPC is a resource for HIPAA-required transaction implementation guides and code

sets. Workgroup for Electronic Data Interchange (WEDI)

o WEDI is a workgroup dedicated to improving health care through electronic commerce, which includes the Strategic National Implementation Process (SNIP) for complying with the Administrative Simplification provisions of HIPAA.

Fraud, Waste and Abuse The Plan is committed to detecting, reporting and preventing potential fraud, waste and abuse (FWA). FWA is defined as: Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in an unauthorized benefit to that person or another person. This term includes an act that constitutes fraud under applicable federal or state law. (42 CFR 433.304).



Abuse: Gross negligence or reckless disregard for the truth in a manner that could result in an unauthorized benefit and unnecessary costs, either directly or indirectly. Waste: A over-utilization of services or improper billing practices that result in unnecessary costs. Generally, not considered caused by criminally negligent action but rather the misuse of resources.

Member Fraud: If a Provider suspects a member has engaged in ID fraud, drug-seeking behavior, or any other fraudulent behavior, this should be reported to the Plan’s Compliance Department. The Plan has a FWA Prevention Program which includes controls designed to prevent and detect potential and suspected FWA activities. Controls and activities are detailed in the Plan’s policies and procedures, and include: Provider credentialing activities to include verification of information provided on credentialing and re-

credentialing applications, and monitoring for inaccurate information or false statements about credentials.

Verification of Associates, FDRs, providers, and vendors for regulatory exclusions prior to hire or contract, at the time of hire or contract, contract renewal, or re-credentialing, and monthly, including:

o Federal List of Excluded Individuals and Entities (LEIE); o Federal System for Award Management (SAM), formerly the EPLS Exclusions Database; o Health Integrity and Protection Data Bank (HIPDB) – initial and re-credentialing; and o Medicaid eligible provider list for Medicaid providers.

Review of claims at the time of processing, including verification of all required elements for claims processing, as outlined in claims processing procedures.

Review of claims payments data for analysis of potential FWA activity including provider profiling and monitoring of contracted and non-contracted providers for:

o Demonstrated patterns of submitting falsified claims, encounters, or service reports; o Demonstrated patterns of overstated reports or up-coding levels of service; o Clinical record documentation that is altered, falsified, or destroyed; o Misrepresentation of clinical information to justify patient referrals; o Failure to provide medically necessary covered services required by the provider contract; o Charging patients for covered services; and o Billing for services not rendered.

Processes for organization and provider verification of members’ identity. Processes to verify whether services billed were provided, based on member complaints and review

of claims issues, including review of the clinical record. Prior authorizations for specified services. Utilization management services, including provider requests and patterns of over or underutilization. Provider contract provisions. Provider member handbook provisions. Standards of Conduct and the Code of Ethics provisions.

Reporting FWA All Providers are responsible for preventing, detecting and correcting FWA and reporting suspected issues to the Argus Compliance Officer. Providers may report suspected FWA issues confidentially and without fear of retaliation, with their identity protected, for reporting alleged FWA in good faith. Reporting FWA issues can be made to any of the following, 24 hours a day/7 days a week: Report to: Argus Compliance OTRS ticketing Email: [email protected]


Argus Compliance and FWA Hotline: (813) 283-1276 Argus Compliance Fax: (813) 347-9270 Argus Compliance Email: [email protected]

Argus Physical Mail: 4010 W State Street, Tampa, FL 33602 Attn: Compliance There are also external agencies to report concerns involving noncompliance, FWA and HIPAA: Florida State Attorney General: 1-866-966-7226 Department of Financial Services, Division of Insurance Fraud: 1-800-378-0445 Department of Health & Human Services, Office of Inspector General: 1-800-447-8477

The Compliance Officer, or designee, receives reports of potential FWA issues and initiates an investigation, corrects the identified problems, follows-up on any required action, and reports to external organizations and entities as required under state and federal laws, and according to health plan contracts. As of January 1, 2017, all physicians will be required to forward a co-pay of CMS’s FWA completion certificate. Please fax this document into the Provider Relations Department. Office Compliance Verification Procedures The Plan’s Providers are expected to meet minimum standards with regards to appointment availability., including:

Emergency- immediately. Urgent Care- within 24 hours. Routine Sick Patient Care- within 7 days. Well Care Visit- within 4 weeks. Follow-up Services- within one (1) month after assessment.

Reimbursement to optometrist/ophthalmologists for vision treatment rendered can come from any number of sources such as individuals, employers, insurance companies and local, state or federal government. The source of monies varies depending on the particular program. For example, in traditional insurance, the physician reimbursement is composed of an insurance payment and a patient coinsurance payment.

XI. Cultural Competency Plan Argus’ Cultural Competency Plan (CCP) addresses issues of disparities and bias that can affect the quality of healthcare. Argus is keenly aware that it provides services to a population that is continuously evolving into a highly diverse and multicultural population. Our goal is to provide services to members in a manner sensitive to the cultural background religious beliefs, values and traditions. Furthermore, Argus strives to provide all information in a culturally competent manner that assists all individuals in obtaining healthcare services. This includes those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds or physical-mental disability issues. The role and objectives of the Cultural Competency Plan are to meet our standards that members receive services in a manner that is responsive to their cultural and linguistic needs while monitoring for disparities occurring in our network. Argus carries out continuous efforts to monitor and evaluate the effectiveness of the CCP and will implement interventions to meet our standards and objectives. Argus’ Cultural Competency Plan primarily focuses its objectives on the National Culturally and Linguistically Appropriate Services (CLAS) Standards. These standards were developed by the United States Department of Health and Human Services’ Office of Minority Health and provide fifteen (15) standards. These Standards “are intended to advance health equity, improve quality and help eliminate health care disparities by establishing a blueprint for health and health care organizations.” A list of these standards can be found at the following link:


https://www.thinkculturalhealth.hhs.gov/Content/clasvid.asp. Argus ensures that all members have access to services in their preferred language by the following measures:

The Customer Care Call Center will be staffed with sufficient bi-lingual personnel to accommodate the diverse linguistic needs of our membership.

All staff with member and provider contact have access to a telephonic language interpretation service that is free of charge to the member. This service provides translation in more than 170 languages to enable communication to the member in their preferred language. Argus staff is trained in utilizing the service.

Member materials are made available in Spanish. Members who indicate a preference in a language other than English will receive member materials, such as handbooks, in their requested language and at no additional cost to the member.

Argus’ Customer Care associates have access to a relay service to support handling of Text Telephone (TTY) and Telecommunication Device for the Deaf (TDD) phone calls. Argus continues to make members and providers aware that this TTY/TTD service is available.

All member complaints related to cultural competency should be directed to Argus’ Quality Improvement Department at [email protected]. A copy of Argus’ Cultural Competency Plan is available on the Argus website at https://argusdental.com/cultural-competency/.

XII. Plan Design Schedules Plan design schedules are located on the Argus Provider Portal, under “Related Documents.” You may also request a copy of the plan design and fee schedule(s) via email to Provider Relations Department at: [email protected].

Forms Provider Application forms: Argus Application including copies of the Provider State License, DEA, Mal Practice Insurance

Certificate and Fellowship Certification W-9 DOO Direct Deposit Enrollment Form Pre-Authorization Request Form Provider Change Form

XIII. Risk Management Providers have an affirmative duty to participate in and cooperate with the Argus Risk Management Program. This includes the requirement to report any adverse identifiable risk issues, injuries, and adverse incidents to the Risk Manager within 24 hours of identification of an incident. The Risk Management Program complies with §59A-12.012, Florida Administrative Code and §641.55, Florida Statute. An adverse incident is defined as any of the following:

1. Any unexpected occurrence that occurs during the provision of health care to a patient and results in death, serious physical injury, psychological injury, illness, loss of limb or function, brain death or spinal cord injury, that is not related to the natural course of the patient’s illness or underlying condition.

https://www.thinkculturalhealth.hhs.gov/Content/clasvid.asp


https://argusdental.com/cultural-competency/



2. Any process variation for which a recurrence carries a significant chance of a serious adverse outcome. 3. Events such as actual breaches in medical care, administrative procedures, or others resulting in an

outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service for a member, including reactions to drugs and materials.

4. Circumstances or events that could have resulted in an adverse event (“near miss” events). 5. Any event that results in an adverse outcome, where the eye care provided did not meet applicable

standards of care or acceptable risk. Breach in care may include eye care, medical care, or may result from administrative procedures or associated activities. Events may include: An event that occurs as a result of medical intervention to which the patient has not given his

informed consent. An event that occurs as a result of an action or lack thereof on the part of the facility or

personnel of the facility. 6. An event which meets all of the following criteria:

It is one in which health care personnel could exercise control; It is associated in whole or in part with a medical intervention other than the condition for

which such intervention occurred; It is not related to the natural course of the patient’s illness or underlying condition; It is not consistent with or expected to be a consequence of such medical intervention; and

It causes injury to a patient as outlined in number one (1) above. 7. Any surgical procedure that is:

Performed on the wrong patient or on the wrong site; Unrelated to the patient’s diagnosis or medical needs being performed on any patient; Surgical removal of foreign objects from previous surgical procedure; or Surgical repair of damage from previous surgical procedure.

When an incident occurs, the Provider must complete the Adverse Incident Report form and fax to the Risk Manager at 813.347.9270. The Risk Manager can assist the Provider in completing this form, and can be contacted at 813.283.1276.



















Employer identification number

Part I

Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

Social security number

–

–

TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Part II Certification

Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage

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FormW-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax classification:

Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Exempt payee

Other (see instructions) ▶

Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

City, state, and ZIP code

List account number(s) here (optional)


interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt

payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of

Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.

effectively connected income.

Sign Here

Signature of U.S. person ▶

Page 2 Form W-9 (Rev. 12-2011)


The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: • The U.S. owner of a disregarded entity and not the entity, • The U.S. grantor or other owner of a grantor trust and not the trust, and • The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person, do not use Form W-9. Instead, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the

saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption

from tax. 5. Sufficient facts to justify the exemption from tax under the terms of

the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an

exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the Part II

instructions on page 3 for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding

because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9.

Also see Special rules for partnerships on page 1.

Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies.

Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions Name If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name.

If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form. Sole proprietor. Enter your individual name as shown on your income tax return on the “Name” line. You may enter your business, trade, or “doing business as (DBA)” name on the “Business name/disregarded entity name” line. Partnership, C Corporation, or S Corporation. Enter the entity's name on the “Name” line and any business, trade, or “doing business as (DBA) name” on the “Business name/disregarded entity name” line. Disregarded entity. Enter the owner's name on the “Name” line. The name of the entity entered on the “Name” line should never be a disregarded entity. The name on the “Name” line must be the name shown on the income tax return on which the income will be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a domestic owner, the domestic owner's name is required to be provided on the “Name” line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the “Business name/disregarded entity name” line. If the owner of the disregarded entity is a foreign person, you must complete an appropriate Form W-8. Note. Check the appropriate box for the federal tax classification of the person whose name is entered on the “Name” line (Individual/sole proprietor, Partnership, C Corporation, S Corporation, Trust/estate). Limited Liability Company (LLC). If the person identified on the “Name” line is an LLC, check the “Limited liability company” box only and enter the appropriate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal tax purposes, enter “P” for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for C corporation or “S” for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section 301.7701-3 (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the “Name” line) is another LLC that is not disregarded for federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner identified on the “Name” line.

Page 3 Form W-9 (Rev. 12-2011)


Other entities. Enter your business name as shown on required federal tax documents on the “Name” line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the “Business name/ disregarded entity name” line.

Exempt Payee If you are exempt from backup withholding, enter your name as described above and check the appropriate box for your status, then check the “Exempt payee” box in the line following the “Business name/ disregarded entity name,” sign and date the form.

Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding.

The following payees are exempt from backup withholding: 1. An organization exempt from tax under section 501(a), any IRA, or a

custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2),

2. The United States or any of its agencies or instrumentalities, 3. A state, the District of Columbia, a possession of the United States,

or any of their political subdivisions or instrumentalities, 4. A foreign government or any of its political subdivisions, agencies,

or instrumentalities, or 5. An international organization or any of its agencies or

instrumentalities. Other payees that may be exempt from backup withholding include: 6. A corporation, 7. A foreign central bank of issue, 8. A dealer in securities or commodities required to register in the

United States, the District of Columbia, or a possession of the United States,

9. A futures commission merchant registered with the Commodity Futures Trading Commission,

10. A real estate investment trust, 11. An entity registered at all times during the tax year under the

Investment Company Act of 1940, 12. A common trust fund operated by a bank under section 584(a), 13. A financial institution, 14. A middleman known in the investment community as a nominee or

custodian, or 15. A trust exempt from tax under section 664 or described in section

4947. The following chart shows types of payments that may be exempt

from backup withholding. The chart applies to the exempt payees listed above, 1 through 15.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except for 9

Broker transactions Exempt payees 1 through 5 and 7 through 13. Also, C corporations.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 5

Payments over $600 required to be reported and direct sales over $5,000 1

Generally, exempt payees 1 through 7 2

1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form

1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency.

Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8.

Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, below, and items 4 and 5 on page 4 indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on the “Name” line must sign. Exempt payees, see Exempt Payee on page 3. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page 4.

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

http://www.ssa.gov/

http://www.irs.gov/businesses


4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester

For this type of account: Give name and SSN of:

1. Individual The individual 2. Two or more individuals (joint

account) The actual owner of the account or, if combined funds, the first individual on the account 1

3. Custodian account of a minor (Uniform Gift to Minors Act)

The minor 2

4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law

The grantor-trustee 1

The actual owner 1

5. Sole proprietorship or disregarded entity owned by an individual

The owner 3

6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulation section 1.671-4(b)(2)(i)(A))

The grantor*

For this type of account: Give name and EIN of: 7. Disregarded entity not owned by an

individual The owner

8. A valid trust, estate, or pension trust Legal entity 4

9. Corporation or LLC electing corporate status on Form 8832 or Form 2553

The corporation

10. Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

11. Partnership or multi-member LLC The partnership 12. A broker or registered nominee The broker or nominee 13. Account with the Department of

Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The public entity

14. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section 1.671-4(b)(2)(i)(B))

The trust

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name and you may also enter your business or “DBA” name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this messageto [email protected]. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: [email protected] or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District

of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.



http://www.ftc.gov/idtheft


July 10, 2017 Dear Vision Provider, As you know, the diabetic patient population can be difficult to manage. Though often noncompliant when it comes to vision care, this group is more likely to take a proactive role in their treatment by keeping appointments for care-critical dilated eye exams when their Primary Care Physicians (PCPs) support the need and are in direct contact with their Eye Care Professionals (ECPs). This also means medical records and reporting alike must be complete, consistent and current to ensure a proper continuum of patient care. For these reasons, Argus Vision and its contractual subsidiary Excedis, Inc., is aiming to dually improve medical record quality, while fostering an open dialogue between referring PCPs and our vision network ECPs, through its “Make It Count” initiative. To guarantee a compliant patient record and confirm that any audit activity is completed with minimal questions, please ensure that your files, EMR output and correspondence include ALL of these required items:

• Patient’s full name (ex. John J. Doe) • Patient’s DOB (ex. 01/01/1945 or January 1, 1945) • Patient’s health plan member ID • Full date of service (ex: 03/12/2016 or March 12, 2016) • Physician’s printed full name, including professional credentials (ex. John Smith, O.D.) • Physician’s signature (full name, including professional credentials) – handwritten or electronic; stamps are unacceptable • Significant illnesses/examination findings, including the presence or absence of diabetic retinopathy in diabetic patients after

completion of a dilated exam, must be noted (ex. Diabetes mellitus, Type II, without complications). Note: Diabetics with ophthalmic complications must include the ICD-10 diagnosis code describing the type of complication (ex. E11.329 – Nonprolif, mild DR, no ME - *see enclosed Coding and Records Quality Guide)

• Diagnoses consistent with examination findings • Treatment plans must be consistent with diagnoses • Date of correspondence - Note on ECP to PCP communication; **see enclosed Diabetic Eye Exam Report • Physician’s place of service address, phone, and fax number – Note on ECP to PCP communication; **see enclosed Diabetic Eye

Exam Report • Any handwritten documentation must be clearly legible to all reviewers other than the author; electronic or typewritten

records are strongly encouraged.

Call to Action: Please review the three enclosures, each included to support DRE gap closures for diabetic patients and ease of communication between ECP and PCP: * Coding and Records Quality Guide: Complete ICD-10, CPT, HCPCS and Records Quality Guide for Documenting Diabetic Patients **Diabetic Eye Exam Communication Form: Following a qualifying dilated procedure, please send this communication to the diabetic patient’s PCP with complete examination results. ***Attestation: Sign, date and return to HEDIS-Vision Team secure Efax 813.425.1951 to attest to understanding and application of all concepts herein. For any questions or concerns, please contact our team by email at [email protected] or Secure Efax at 813.425.1951. Sincerely, Excedis HEDIS-Vision Team



Make Your Records Count!

Before Billing or Completing the Record of a Diabetic Member, Please Review These NCQA-Criteria:

Qualifying ICD10-CM Diagnosis Codes

E10.9, E11.9, E13.9 Diabetes without ocular complications E10.311, E10.321, E10.329, E10.331, E10.339, E10.39, E10.341, E10.349, E10.351, E10.359, E10.65 Type I diabetes with ocular complications

E11.319, E11.321, E11.331, E11.329, E11.339, E11.341, E11.349, E11.351, E11.359, E11.65 Type II diabetes with ocular complications

Qualifying CPT Procedure Codes (that satisfy the DRE measurement)

92004 New patient; routine comprehensive eye exam, including dilation and evaluation with diagnostic treatment 92014 Established patient; routine comprehensive eye exam, including dilation and evaluation with diagnostic treatment 92002 New patient; routine intermediate exam, usually including dilation and evaluation with diagnostic treatment 92012 Established patient; routine intermediate exam, usually including dilation and evaluation with diagnostic treatment 92018 92019

Ophthalmological exam and evaluation, under general anesthesia, with/without manipulation of glove for passive range of motion or other manipulation to facilitate diagnostic examination

92225 Initial visit; ophthalmoscopy, extended, with retinal drawing, interpretation and report 92225 Follow up visit; ophthalmoscopy, extended, with retinal drawing, interpretation and report

92227 Remote imaging (non-mydriatic) for detection of retinal disease with analysis and report under physician supervision, either unilateral or bilateral; this screening service may/may not identify retinal disease; does not require formal interpretation

92228 Remote imaging (non-mydriatic) for detection of retinal disease with analysis and report under physician supervision, either unilateral or bilateral; assesses a present retinal disease (i.e., retinopathy); requires formal interpretation

67028 Intravitreal injection 67030 Incise inner eye strands 67031 Laser surgery; eye strands 67036 Remove inner eye fluid 67039, 67040 67041, 67042 Vitrechtomy procedures

67101, 67105 67107, 67108 67110, 67112

Retinal detachment repair

67113 Repair of complex retinal detachment (proliferative vitreoretinopathy, stage C-1 or greater; diabetic traction retinal detachment, retinopathy of prematurity; retinal tear of greater than 90°), with vitrectomy and membrane peeling, etc.

67121 Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques

67141 67145 Retinal repairs under prophalaxis

67208, 67210 Destruction of localized lesion of retinal (i.e., macular edema, tumors, etc.); 1 or more sessions with photocoagulation 67218 Destruction procedure on retina or choroid

67220 Destruction of localized lesion of choroid (i.e., choroidal neovascularization); photocoagulation 1 or more sessions with photocoagulation

67221 Photodynamic therapy with verteporfin 67227 Destruction of extensive or progressive retinopathy via cryotherapy, diathermy, etc. 67228 Treatment of extensive or progressive retinopathy with photocoagulation 92230 Fluorescein angioscopy 92235 Fluorescein angiography 92240 Indocyanine; green angiography 92250 Bilateral fundus photography with interpretation and report 92260 Ophthalmodynamometry 92203, 99213 Level 3 visit (office or outpatient) with detailed history, exam and/or low-complexity medical decisions 99204, 99214 Level 4 visit (office or outpatient) with detailed history, exam and/or complex medical decisions 99205, 99215 These codes are rarely used 99242,99243 99244, 99245 Office consultation


Qualifying HCPCS Codes (Healthcare Common Procedure Coding System)

S0620 New patient; routine ophthalmological examination, including dilation and refraction S0621 Established patient; routine ophthalmological examination, including dilation and refraction

S3000 Diabetic indicator; retinal, bilateral dilated eye exam, often used to screen and measure the presence of retinopathy or report its absence; PCPs may use this code on referrals to assist the ECP in identifying that this consultation is to screen for diabetic retinopathy

Qualifying CPT Reporting Codes

2022F Dilated retinal exam with interpretation by ophthalmologist or optometrist; documented and reviewed 2024F Seven standard field stereoscopic photos with interpretation by ophthalmologist or optometrist; documented and reviewed 2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos; results documented and reviewed 3072F No evidence of retinopathy in the prior year

NCQA Quality Criteria for Proper Records Documentation To guarantee a comprehensive patient record and confirm that any Excedis-directed audit activity is completed with minimal questions, please review that your files, EMR output and all correspondence include these details, at a minimum:

• Patient’s full name (ex. John J. Doe) • Patient’s DOB (ex. 01/01/1945 or January 1, 1945) • Patient’s health plan member ID • Full date of service (ex: 03/12/2016 or March 12, 2016) • Physician’s printed name with professional credentials (ex. John Smith, O.D.) • Physician’s signature with professional credentials – handwritten or electronic; stamps are unacceptable • Significant illnesses/examination findings must be noted, including the presence or absence of diabetic retinopathy in diabetic patients after

completion of a dilated exam (ex. Diabetes mellitus, Type II, without complications). Note: Diabetics with ophthalmic complications must also include the ICD-10 diagnosis code describing the type of complication (ex. E11.329 – Nonprolif, mild DR, no ME)

• Date of correspondence - Note on ECP to PCP communication • Physician’s place of service address, phone, and fax number – Note on ECP to PCP communication • Diagnoses consistent with examination findings • Treatment plans must be consistent with diagnoses • Any handwritten documentation must be clearly legible to all reviewers; electronic or typewritten records are strongly encouraged.

Following these guidelines will help make your records count!




Review of “Make It Count” Materials: Letter of Attestation

***This document must be signed and returned to Excedis no later than COB August 4, 2017. Please forward to Excedis at [email protected] or via secure E-fax at 813.425.1951.

On behalf of (office name & location), _____________________________________________________________________________, I hereby attest that I have reviewed the “Make It Count” letter and all corresponding enclosures as follows:

1. “Make It Count” Letter 2. Coding and Quality Guide 3. Diabetic Eye Examination Report

Our practice will apply and adhere to the best-practice guidelines covered in the letter and coding & quality guide. Additionally, my practice understands that this document may be referenced by the Health Plan during or following any audit, and may be used as justification for further audits or remediation should our patients’ vision records be found to be out of compliance. I declare the above statement to be true and accurate. Sincerely, ______________________________ _________________________ Vision Practice Staff - Signature Excedis Vision Staff – Counter Signature

______________________________ _________________________ Vision Practice Staff – Printed Name Excedis Vision Staff – Printed Name ______________________________ _________________________ Date Signed by Vision Practice Staff Date Signed by Excedis Vision Staff



2017 PROVIDER MANUAL Argus Dental & Vision, Inc.

4010 W. State Street, Tampa, FL 33609 877-864-0625 ext. 175

www.argusdentalvision.com PR V Manual 7/17. For Provider Use Only.