Table of Contents Eye and Vision Services 1 1.Important

Idaho Medicaid Provider Handbook Eye and Vision Services

October 28, 2020 Page i

Table of Contents

Eye and Vision Services ................................................. 1

1.Important Contacts ..................................................... 2 1.1. Gainwell Technologies........................................ Error! Bookmark not defined.

1.2. Provider Relations Consultants ....................................................................... 3

1.3. Medicaid ..................................................................................................... 4

1.4. National Vision Administrators ....................................................................... 5

2.Provider Qualifications............................................... 6 2.1. Ophthalmologists ......................................................................................... 6

2.1.1. References: Ophthalmologists .................................................................. 6

2.2. Opticians .................................................................................................... 7

2.2.1. References: Opticians ............................................................................. 7

2.3. Optometrists ............................................................................................... 8

2.3.1. References: Optometrists ........................................................................ 8

3.Eligible Participants ................................................... 9 3.1. Referrals ................................................................................................... 10

3.2. Age Restrictions ......................................................................................... 11

3.2.1. References: Age Restrictions ................................................................. 11

3.3. EPSDT Services for Participants Under 21 ...................................................... 12

4. Covered Services and Limitations: Contact Lenses and

Eyeglasses ................................................................... 13 4.1. References: Covered Services and Limitations – Contact Lenses and Eyeglasses . 13

4.1.1. Federal Regulations .............................................................................. 13

4.1.2. State Regulations ................................................................................. 13

4.2. Contact Lenses .......................................................................................... 14

4.2.1. References: Contact Lenses ................................................................... 14

4.2.2. Contact Lens Bandage .......................................................................... 16

4.2.3. Contact Lenses for Keratoconus ............................................................. 17

4.3. Eyeglass Frames ........................................................................................ 18

4.3.1. References: Eyeglass Frames ................................................................. 18

4.3.2. Deluxe (Specialty) Frames .................................................................... 20

4.4. Eyeglass Lenses ......................................................................................... 21

4.4.1. References: Eyeglass Lenses ................................................................. 21

4.4.2. Aspheric Lenses ................................................................................... 23

4.4.3. High Index Lens Material ....................................................................... 24

4.4.4. Lenticular Lens Material ........................................................................ 25

4.4.5. Photochromatic/Transition Lenses .......................................................... 26

4.4.6. Progressive Lenses ............................................................................... 27

4.4.7. Tinted Lenses ...................................................................................... 28

4.4.8. Trifocal Lenses .................................................................................... 29

4.5. Eye Glasses for Cataract Surgery ................................................................. 30

4.6. Miscellaneous Supply .................................................................................. 31


December 16, 2020 Page ii of 149

4.7. Fitting Fee/Dispensing Fee .......................................................................... 32

4.7.1. References: Fitting Fee/Dispensing Fee ................................................... 32

4.8. Non-Covered Services ................................................................................ 33

4.8.1. References: Non-Covered Services ......................................................... 33

5.Covered Services and Limitations: Examinations and

Diagnostics .................................................................. 34 5.1. References: Covered Services and Limitations: Examinations and Diagnostics .... 34


5.1.2. Idaho Medicaid Publications ................................................................... 34

5.1.3. Idaho State Plan .................................................................................. 35


5.2. New and Established Patient Exams .............................................................. 36

5.3. Comprehensive Ophthalmological Services .................................................... 37

5.4. Intermediate Ophthalmological Services ........................................................ 38

5.5. Evaluation and Management ........................................................................ 39

5.5.1. References: Evaluation and Management ................................................ 39

5.6. Fundus Photography ................................................................................... 40

5.6.1. References: Fundus Photography ........................................................... 40

5.7. Refraction Procedure .................................................................................. 41

5.8. Tonometry ................................................................................................ 42

5.8.1. References: Tonometry ......................................................................... 42

6.Covered Services and Limitations: Pharmaceuticals . 43 6.1. References: Covered Services and Limitations: Pharmaceuticals ....................... 43


7.Covered Services and Limitations: Surgery and

Procedures .................................................................. 44 7.1. Optometrists Performing Procedures ............................................................. 45

7.1.1. References: Optometrists Performing Procedures ...................................... 45

7.2. Blepharoplasty .......................................................................................... 46

7.2.1. References: Blepharoplasty ................................................................... 46

7.3. Corneal Transplants ................................................................................... 48

7.4. Lasik ........................................................................................................ 49

7.4.1. References: Lasik ................................................................................. 49

7.5. Photorefractive Keratectomy ........................................................................ 50

7.5.1. References: Photorefractive Keratectomy ................................................ 50

8.Covered Services and Limitations: Therapy Services 51 8.1. References: Covered Services and Limitations – Therapy Services .................... 51



8.2. Eye Exercise Therapy ................................................................................. 52

8.3. Interactive Metronome Therapy ................................................................... 52

8.4. Vision Therapy........................................................................................... 53

8.4.1. Vision Therapy: Provider Qualifications .................................................... 53


December 16, 2020 Page iii of 149

8.4.2. Vision Therapy: Eligible Participants ........................................................ 53

8.4.3. Vision Therapy: Coverage and Limitations ............................................... 53

8.4.4. Vision Therapy: Additional Documentation ............................................... 54

8.4.5. Vision Therapy: Prior Authorization (PA) Requests .................................... 54

8.4.6. References: Vision Therapy ................................................................... 55

8.5. Visual Processing Therapy ........................................................................... 57

8.5.1. Literature Review ................................................................................. 57

8.5.2. References: Visual Processing Therapy .................................................... 58

9.Documentation Requirements .................................. 60

10.Prior Authorization Requests ................................. 61 10.1. Prior Authorization Requests: Medical Care Unit .......................................... 61

10.2. Prior Authorization Requests: NVA ............................................................. 61

11.Reimbursement ....................................................... 62 11.1. References: Reimbursement ..................................................................... 62

11.1.1. Federal Regulations ........................................................................... 62

11.1.2. Idaho Medicaid Publications ................................................................ 62

11.1.3. Idaho State Plan ............................................................................... 63

11.1.4. State Regulations .............................................................................. 63

11.2. Medicare Crossovers for Vision Services ..................................................... 64

11.3. Third Party Insurance Billing ..................................................................... 65

Appendix A. Preapproved Diagnoses for Chronic and Acute Conditions ....................... 66

a) References: Preapproved Diagnoses for Chronic and Acute Conditions .................. 69

i) Idaho Medicaid Publications ......................................................................... 69

Appendix B. Frame Brochure for Idaho Medicaid Vision Products ............................... 71

a) V2020 Child Frame List .................................................................................. 72

b) V2025 Child Frame List .................................................................................. 78

c) V2020 Adult Frame List .................................................................................. 80

d) V2025 Adult Frame List .................................................................................. 85

e) V2020 Frames Listed by Size .......................................................................... 86

f) V2025 Frames Listed by Size – Prior Authorization Required ................................ 94

g) V2020 Frame Descriptions .............................................................................. 96

h) V2025 Frame Descriptions ............................................................................. 130

i) New V2025 Frames ...................................................................................... 141

j) Frame Size and Color Chart ........................................................................... 143

Appendix C. Eye and Vision Services, Provider Handbook Modifications ..................... 144


December 16, 2020 Page 1 of 149

Eye and Vision Services This section covers all Medicaid vision services provided through Opticians, Optometrists, and Ophthalmologists as deemed appropriate by the Department of Health and Welfare (DHW).

These specialties are identified as vision services throughout this document. Sections of the Idaho Medicaid Provider Handbook applicable in specific situations are listed throughout the

handbook for provider convenience. Handbook sections that always apply to this provider type include the following:

• General Billing Instructions; • General Information and Requirements for Providers; and

• Glossary.

Handbooks can only be used properly in context. Providers must be familiar with the

handbooks that affect them and their services. The numbering in handbooks is also important to make note of as subsections rely on the content of the sections above them.

Example

Section 1.2.3.a The Answer requires the reader to have also read Section 1, Section 1.2 and Section 1.2.3 to be able to properly apply Section 1.2.3.a.

• References are included throughout the handbook for provider and staff convenience.

Not all applicable references have been incorporated into the handbook. Not all references provided are equal in weight.

• Case Law: Includes references to court cases that established interpretations of law that states and providers would be required to follow.

• CMS Guidance: These references reflect various Centers for Medicare and Medicaid Services (CMS) publications that Idaho Medicaid reviewed in the formulation of their

policy. The publications themselves are not required to be followed for Idaho Medicaid

services. • Federal Regulations: These references are regulations from the federal level that

affected policy development. Usually these include the Code of Federal Regulations, the Social Security Act and other statutes. They are required to be followed.

• Idaho Medicaid Publications: These are communications from Idaho Medicaid to providers that were required to be followed when published. These are included in the

handbook for historical reference. The provider handbook supersedes other communications unless the documents are listed in the Department’s Rules, Statutes,

and Policies webpage under policies in Medicaid’s department library.

• Idaho State Plan: The State Plan is the agreement between the State of Idaho and the Centers for Medicare and Medicaid Services on how the State will administer its medical

assistance program. • Professional Organizations: These references reflect various publications of

professional organizations that Idaho Medicaid reviewed in the formulation of their policy. Providers may or may not be required to follow these references, depending on

the individual reference and its application to a provider’s licensure and scope of practice.

• State Regulations: These references are regulations from the state level that affected

policy development. They usually include statute and IDAPA. They are required to be followed.

• Scholarly Work: These references are publications that Idaho Medicaid reviewed in the formulation of their policy. The publications themselves are not required to be followed

for Idaho Medicaid services.

https://www.idmedicaid.com/General%20Information/General%20Billing%20Instructions.pdf

https://www.idmedicaid.com/General%20Information/General%20Information%20and%20Requirements%20for%20Providers.pdf

https://www.idmedicaid.com/Reference/Glossary.pdf

https://healthandwelfare.idaho.gov/AboutUs/RulesStatutes/tabid/133/Default.aspx

https://healthandwelfare.idaho.gov/AboutUs/RulesStatutes/tabid/133/Default.aspx

https://publicdocuments.dhw.idaho.gov/WebLink/Browse.aspx?id=12&dbid=0&repo=PUBLIC-DOCUMENTS



1. Important Contacts The Directory, Idaho Medicaid Provider Handbook contains a comprehensive list of contacts. The following contacts are presented here for convenience.

Gainwell Technologies Gainwell Technologies is Idaho Medicaid’s fiscal agent that handles all claims processing and customer service issues.

Gainwell Contact Information

Gainwell Technologies Provider Services

P.O. Box 70082 Boise, ID 83707

Phone: 1 (888) 686-4272 Fax: 1 (877) 661-0974

[email protected]

The Medicaid Automated Call Service (MACS) is available 24 hours a day, seven days a

week. Provider service representatives are available Monday through Friday, 7:00 A.M.-7:00 P.M. MT.

Provider Enrollment P.O. Box 70082

Boise, ID 83707 Phone: 1 (866) 686-4272

Fax: 1 (877) 517-2041 [email protected]

Technical Services

Phone: 1 (866) 686-4272

Fax: 1 (877) 517-2040 [email protected]

https://www.idmedicaid.com/General%20Information/Directory.pdf

https://www.idmedicaid.com/default.aspx

mailto:[email protected]





Provider Relations Consultants Gainwell Technologies Provider Relations Consultants help keep providers up-to-date on billing changes required by program policy changes implemented by the Division of Medicaid.

Provider Relations Consultants accomplish this by: • Conducting provider workshops;

• Conducting live meetings for training; • Visiting a provider’s site to conduct training; and

• Assisting providers with electronic claims submission



Medicaid The Medical Care Unit is Idaho Medicaid’s team that reviews prior authorization requests for additional examinations and some surgical procedures.

Medical Care Unit

PO Box 83720 Boise, ID 83720-0009

Phone 1 (866) 205-7403

Fax 1 (877) 314-8779 [email protected]

The status of a prior authorization request submitted to the Medical Care Unit may be checked

online at the Gainwell Technologies portal under “Authorization Status”, using your NPI. If you have questions on a Denial, click on the Notes, which will explain the reason for the

Denial.

mailto:[email protected]?subject=DME

https://www.idmedicaid.com/Default.aspx



National Vision Administrators National Vision Administrators (NVA) reviews prior authorization requests for glasses and contact lenses.

National Vison Administrators, L.L.C.

Attn: Idaho Medicaid Prior Approvals 1200 Route 46 West

Clifton, NJ 07013

Phone: 1 (877) 626-2969 Fax: 1 (888) 483-6830

www.e-nva.com

Providers can view the outcome of their prior authorization request from NVA by logging into their account at www.e-nva.com, or calling 1 (877) 626-2969.

https://www.e-nva.com/nva/content/home/home.xhtml

http://www.e-nva.com/




2. Provider Qualifications

Ophthalmologists An ophthalmologist is a medical or osteopathic doctor who specializes in the eye and vision. Ophthalmologists in any state are eligible to participate in the Idaho Medicaid Program. They

must have a National Provider Identification (NPI). They must be licensed in the state where the services are performed and enrolled as an Idaho Medicaid provider prior to submitting

claims for services. As physicians, ophthalmologists are eligible to be ordering, prescribing, referring and rendering providers.

Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the Physician and Non-Physician Practitioner,

Idaho Medicaid Handbook for all physician allowances and requirements. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more

information on enrolling as an Idaho Medicaid provider.

2.1.1. References: Ophthalmologists

a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social

Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.

b) State Regulations “Physician.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 012.04. Office of the

Administrative Rules Coordinator, Division of Financial Management, State of Idaho,

https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Physician Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 500. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


https://www.idmedicaid.com/Provider%20Guidelines/Physician%20and%20Non-Physician%20Practitioner.pdf



https://www.ssa.gov/OP_Home/ssact/title19/1905.htm


https://adminrules.idaho.gov/rules/current/16/160309.pdf




Opticians

An optician is a professional that engages in the practice of filling prescriptions for eyeglasses and contact lenses and does not have prescriptive authority. The services of the optician are

generally bundled into the payment for the services of the optometrist or ophthalmologist. However, opticians can enroll with Idaho Medicaid to bill for certain services. Fitting fees and

dispensing fees in particular are reimbursable. Services provided by an optician working under an enrolled optometrist or ophthalmologist can be billed using the optometrist or

ophthalmologist’s national provider identification (NPI). Opticians enrolling with Idaho

Medicaid must have their own National Provider Identification (NPI).

Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the General Information and Requirements for

Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho Medicaid provider.

2.2.1. References: Opticians

a) State Regulations “Opticianry.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.010.02. Office

of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.






Optometrists Only optometrists licensed in the State of Idaho are eligible to participate in the Idaho Medicaid Program. They must have a National Provider Identification (NPI). Optometrists

must enroll as an Idaho Medicaid provider prior to submitting claims for services. Optometrists certified to treat eye disease must include a copy of that certification with their enrollment.

Optometrists are eligible to be ordering, prescribing, rendering and referring providers.

Providers must follow the guidelines in the provider handbook, in addition to all applicable

state and federal rules and regulations. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho

Medicaid provider.

2.3.1. References: Optometrists

a) State Regulations “Optometrist Services: Provider Qualifications and Duties.” IDAPA 16.03.09, “Medicaid Basic

Plan Benefits,” Sec. 554. Office of the Administrative Rules Coordinator, Division of Financial

Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

IDAPA 24.10.01, “Rules of the State Board of Optometry,” Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


Practice of Optometry Defined, Idaho Code 54-1501 (2009). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1501/.

State Board of Optometry – Powers and Duties, Idaho Code 54-1509 (2009). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1509/.





https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1501/




3. Eligible Participants Participants with Medicaid Basic and Enhanced Plans are eligible to receive vision services based on age restrictions. Providers must check participant eligibility prior to delivery of any

service by calling Idaho Medicaid Automated Customer Service (MACS) at 1 (866) 686-4272; or through the Trading Partner Account on Gainwell Technologies Idaho Medicaid website.

Participants who are covered by Idaho Medicaid but have eligibility restrictions, do not have

vision benefits under Medicaid fee-for-service. These eligibility programs include, but are not limited to:

• Otherwise Ineligible Non-Citizens (OINC);

• Presumptive Eligibility (PE); • Qualified Medicare Beneficiary (QMB) Program only, without another unrestricted

Medicaid eligibility program open; and • Medicare Medicaid Coordinated Plan (MMCP).

When billing for participants enrolled in other benefit plans, refer to General Information and

Requirements for Providers, Idaho Medicaid Provider Handbook for coverage.

https://www.idmedicaid.com/default.aspx





Referrals Vision services performed in the offices of ophthalmologists and optometrists, including the dispensing of eyeglasses, do not require a Healthy Connections (HC) referral. Procedures

performed in an inpatient or outpatient hospital or ambulatory surgery center setting require a referral if the participant is enrolled in HC, Idaho’s Medicaid primary care case management

(PCCM) model of managed care. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information about HC requirements.




Age Restrictions Participants under the age of 21 are eligible for:

• Examinations and vision testing once every 365 days without a prior authorization.

• Eyeglasses every four (4) years without a prior authorization. • Contact lenses with a prior authorization.

• Additional services are covered under EPSDT with a prior authorization if medically necessary to correct or ameliorate defects.

Participants 21 years of age and older are not eligible for routine eye exams, eyeglasses, and contact lenses unless otherwise noted. They are eligible for:

• Examinations and vision testing necessary to monitor a chronic medical condition that may damage the eye such as diabetes. See Appendix A for preapproved diagnoses.

• Services to treat acute conditions that, if left untreated, may cause permanent or chronic damage to the eye. See Appendix A for preapproved diagnoses.

• One pair of eyeglasses or contact lenses following cataract surgery. • Contacts are available with a prior authorization to treat Keratoconus.

• Contact lenses or eyeglasses when necessary to prevent further degradation of vision

due to the existence of a chronic condition. A prior authorization request with supporting documentation must be submitted for review.

3.2.1. References: Age Restrictions

a) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,

https://www.idmedicaid.com/MedicAide%20Newsletters/July%202011%20MedicAide.pdf.

House Bill 260 Budget Reductions – Vision Services, Information Release MA11-11

(5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf.

a) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.

https://www.idmedicaid.com/MedicAide%20Newsletters/July%202011%20MedicAide.pdf

https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf



EPSDT Services for Participants Under 21 Services identified as a result of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and which correct or ameliorate a defect will not be subject to the existing amount,

scope, and duration limitations, but will require a prior authorization. The medical necessity for the additional service must be documented. It must be proven safe, effective and accepted

as a medical practice or treatment for the condition being addressed. Additional information for EPSDT including billing requirements for services approved under EPSDT may be found in

the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.




4. Covered Services and Limitations: Contact Lenses and Eyeglasses

All vision supplies (contact lenses, frames, and lenses,) must have a prescription and be authorized by Medicaid’s contractor National Vision Administrators (NVA). NVA has partnered

with Classic Optical to furnish these supplies. Supplies obtained through any other lab will not be reimbursed by Idaho Medicaid. NVA will bill Medicaid directly for authorized items.

Providers can view, and order vision supplies online from the NVA catalog by logging into the

NVA website (www.e-nva.com). Orders can also be submitted by faxing 1 (888) 522-2022. All orders must contain an authorization number, which may be obtained on the NVA website

or through the NVA Provider Hotline at 1 (877) 626-2969. Authorization numbers are

automatically generated for eligible participants if the item does not require prior approval.

Providers without access to the internet or fax service can mail eyeglasses and contact lens orders with their authorization number to the following address:

Classic Optical

3710 Belmont Ave Youngstown, OH 44505

Some lenses, services and specialty frames require prior authorization/prior approval; please refer to the Prior Authorization Requests section for more information on how to submit a

request.

References: Covered Services and Limitations – Contact Lenses and Eyeglasses

4.1.1. Federal Regulations Prescribed Drugs, Dentures, Prosthetic Devices, and Eyeglasses, 42 C.F.R. Sec. 440.120(d) (1978). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-

title42-vol4/pdf/CFR-2018-title42-vol4-sec440-120.pdf.

4.1.2. State Regulations Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(f) (2018).

Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Prescriptions for Spectacles and Contact Lenses.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.450. Office of the Administrative Rules Coordinator, Division of

Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.

“Vision Services: Provider Reimbursement.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,”

Sec. 785. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.


https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4-sec440-120.pdf


https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/





Contact Lenses Contact lenses will be covered for participants under the age of 21 with extreme myopia or hyperopia requiring a correction equal to, or greater than, minus or plus ten (10.0) diopters

in at least one eye, cataract surgery, keratoconus, anisometropia, or other extreme medical conditions precluding the use of eyeglasses as defined by the Department.

Participants over the age of 21 are eligible for contact lenses when necessary to prevent

further degradation of vision. Medicaid follows Medicare’s LCD (L33793) for determining

coverage.

Orders for contacts should be made through Classic Optical by completing the Contact Lens Order Form (available for download at www.e-nva.com after login). All contact lenses (HCPCS

V2500 – V2599) require a prior authorization from NVA; please refer to the Prior Authorization Requests section for more information on how to submit a request.

4.2.1. References: Contact Lenses

a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration,

https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.

“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,


Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office,

https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42-chap7-subchapXIX-sec1396d.pdf.



Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office,

https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4-sec440-225.pdf.

b) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,


House Bill 701 Budget Reductions – Changes in Vision Benefits, Information Release MA10-

21 (12/01/2010). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/IR%20MA10-

21%20HB701%20Budget%20Reduction%20-%20Vision.pdf.

c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of

Idaho.

https://med.noridianmedicare.com/documents/2230703/7218263/Refractive+Lenses+LCD+and+PA/9b1c50b6-b2de-4da5-b4a7-6f8a9446c702




https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42-chap7-subchapXIX-sec1396d.pdf






https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/IR%20MA10-21%20HB701%20Budget%20Reduction%20-%20Vision.pdf

https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/IR%20MA10-21%20HB701%20Budget%20Reduction%20-%20Vision.pdf



d) State Regulations “Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02.c. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,





4.2.2. Contact Lens Bandage Idaho Medicaid covers the fitting of contact lens for treatment of ocular surface disease for children and adults. The CPT® code 92071 does not require a prior authorization or KX

modifier. The payment for the actual lens is included within the payment for 92071.



4.2.3. Contact Lenses for Keratoconus Available for all ages, gas permeable contact lenses (HCPCS V2510 or V2511) and custom lenses (HCPCS V2599 with quantity 1 or 2) require a Prior Authorization Request. Prior

authorization requests should include the contact lens prior approval form and physician documentation to support the diagnosis of Keratoconus. When requesting custom lenses, note

on the request form “custom made contacts for keratoconus, diagnosis H18.81.”

If you need a fitting kit, contact NVA’s partner, Classic Optical, to discuss the type of kit

and/or specifications needed for special fit, custom-made contact lenses. You may reach Classic Optical at 1-888-522-2020 and a customer service representative will assist you, or

by faxing a request to 1 (888) 522-2022. Fitting kits for Rose K, Jupiter, Custom Stable, McGuire or Dyna Intra Limbal gas permeable lenses are available. Kits are available free of

charge with a prepaid return label. After the trial fit, please clean and disinfect the lenses before returning the kit.

There is a warranty period on custom lenses, during which time you may exchange the

contacts. A new authorization is not needed if the contacts are under warranty. This is a no

charge “exchange in place” replacement. The original unusable contact lenses must be returned to Classic Optical.

a) References: Contact Lenses for Keratoconus

i) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,





Eyeglass Frames Participants under the age of 21 are eligible for a frame (HCPCS V2020) once every four years without a prior authorization. A booklet of available frames is available in Appendix B.

Early Periodic Screening, Diagnosis and Treatment services (EPSDT) may allow for coverage earlier than the four-year limitation with a prior authorization from NVA and documentation

of: • The lenses or frame being lost, damaged beyond use, or the current frames having

been outgrown; or

• New lenses being necessary, and the prescription cannot be accommodated in lenses which fit the existing frames.

Participants over the age of 21 are only eligible for eyeglasses once every four years, when

necessary to prevent further degradation of vision. Frames are only covered under HCPCS V2020. A prior authorization from NVA is necessary; please refer to the Prior Authorization

Request section for more information on how to submit a request. Replacement of broken, lost, or missing glasses is the responsibility of the participant.

NVA will replace frames which break due to normal wear in the first 90 days. If repairs are needed after 90 days, the provider may bill Medicaid for the repairs using CPT® code 92370.

If a participant has a history of repeatedly breaking frames, the vision provider should repair the frame, or request a sturdier frame (HCPCS V2020).

4.3.1. References: Eyeglass Frames










Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4-

sec440-225.pdf.

b) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,













c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.

“Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid,

Attachment 4.19-B. Department of Health and Welfare, State of Idaho.

d) State Regulations “Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of

Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Frames.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


“Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.b. Office







4.3.2. Deluxe (Specialty) Frames Deluxe (Specialty) frames (HCPCS V2025) require a prior authorization request to NVA with documentation of a medical condition that cannot be met by other frames. They are not

available as a replacement for frequent breakage of V2020 frames.

Children under the age of three (3) may qualify with documentation of multiple V2020 frames trialed that do not fit. At a minimum these frames should be considered:

• Cutie metal (32-15-115, 32-15-120);

• L8005 (36-17-140, 38-17-140, 40-18-140); and • Mainstreet 415 plastic with cable temple (33-20-115, 36-20-120, 39-20-125).



Eyeglass Lenses Participants under the age of 21 are eligible for one set of single vision or bifocal lenses once every four (4) years without a prior authorization, except when there is a minimum Rx of 0.50

diopter in at least one eye considering both the spherical and cylindrical prescription. Early Periodic Screening, Diagnosis and Treatment services (EPSDT) may allow for coverage earlier

than the four-year limitation with a prior authorization from NVA and documentation of: • A major visual change that is equal or greater than plus or minus 0.50 diopter in one

eye considering both the spherical and cylindrical prescription; or

• The lenses or frame being lost, damaged beyond use, or the current frames having been outgrown.

Participants over the age of 21 are only eligible for eyeglasses once every four years, when

necessary to prevent further degradation of vision. A prior authorization from NVA is necessary; please refer to the Prior Authorization section for more information on how to

submit a request. Replacement of broken, lost, or missing glasses is the responsibility of the participant.

All plastic and polycarbonate lenses must have scratch resistant coating.

4.4.1. References: Eyeglass Lenses



“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration,


“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm



“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.



b) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide

Newsletter, July 2011, https://www.idmedicaid.com/MedicAide%20Newsletters/July%202011%20MedicAide.pdf.

c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.












“Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment 4.19-B. Department of Health and Welfare, State of Idaho.

d) State Regulations “Eye Examinations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.01.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


“Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06.

Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02. Office of the

Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

“Replacement Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.03. Office

of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


“Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,









4.4.2. Aspheric Lenses Aspheric lenses (HCPCS V2410, V2430 and V2499) are covered with a prior authorization

from NVA and documentation of a plus 8.0 diopter reading or greater.



4.4.3. High Index Lens Material High Index lens material is covered with a prior authorization from NVA and documentation of:

High Index Lens Material

HCPCS Criteria for Coverage

V2782 Minus 4.0 diopter to minus 9.75 diopter prescription in at least one eye. Both spherical

and cylindrical prescription may be added together for the same eye if both numbers are a minus (-).

V2783 Minus 10.0 diopter or higher prescription in at least one eye. Both spherical and

cylindrical prescription may be added together for the same eye if both numbers are a minus (-).



4.4.4. Lenticular Lens Material Lenticular Lens Material (HCPCS V2115, V2121, V2215, V2221) is covered with a prior authorization from NVA and documentation of equal to, or greater than, plus or minus 10.0

diopter prescription in at least one eye. Both the spherical and cylindrical prescription may be added together for the same eye if both numbers are a plus (+) or a minus (-).



4.4.5. Photochromatic/Transition Lenses Photochromatic/Transition lenses (HCPCS V2744) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.” A prior authorization request may be submitted for tinted

lenses instead.

a) References: Photochromatic/Transition Lenses

i) Idaho Medicaid Publications “Idaho Medicaid Vision Program.” MedicAide Newsletter, September 2015, https://www.idmedicaid.com/MedicAide%20Newsletters/September%202015%20MedicAide

.pdf.

ii) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office


https://www.idmedicaid.com/MedicAide%20Newsletters/September%202015%20MedicAide.pdf





4.4.6. Progressive Lenses Progressive lenses (HCPCS V2781) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.”

a) References: Progressive Lenses

i) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office





4.4.7. Tinted Lenses Tinted lenses (HCPCS V2745) require a prior authorization from NVA with supporting documentation of medical necessity such as albinism, or other medical conditions or

ophthalmologic diseases which cause photophobia. Other conditions might be aniridea, aphakia, migraine headaches, retinitis pigmentosa, severe blepharospasm, corneal injury, or

congenital abnormalities. Photophobia alone does not suffice for approval of tinted lenses. Tint can be applied to a solid lens or as a gradient to the lens and based upon a percentage.

A medical diagnosis must also be provided. Lenses are not covered for cosmetic or

convenience purposes.

Requests for a special therapeutic rose-colored tint F41 may be submitted under V2799.

a) References: Tinted Lenses

i) Idaho Medicaid Publications “Idaho Medicaid Vision Program.” MedicAide Newsletter, September 2015,

https://www.idmedicaid.com/MedicAide%20Newsletters/September%202015%20MedicAide

.pdf.

ii) State Regulations “Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02.b. Office of the


“Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office









4.4.8. Trifocal Lenses Trifocal lenses (HCPCS V2300 – V2399) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.”

a) References: Trifocal Lenses

i) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.a. Office





Eye Glasses for Cataract Surgery One pair of eyeglasses is covered for all ages following a recent cataract surgery. The Department follows the Medicare Coverage Determination Guidelines for cataract surgery. A

prior authorization from NVA is necessary, unless the participant has Medicare primary. The prior authorization request must include the date of the cataract surgery, eye(s) treated and

the surgeon’s name.



Miscellaneous Supply All miscellaneous supply codes (HCPCS V2599, V2799) require a prior authorization from NVA. Documentation must include medical necessity, and why the request would be the least costly

means of meeting the participant’s needs.



Fitting Fee/Dispensing Fee Fitting or dispensing of glasses or contact lenses (CPT® 92071, 92072 and 92310–92317) does not require a prior authorization. The dispensing provider may bill Idaho Medicaid for

fitting/dispensing when the new frames or lenses are covered by Medicaid and ordered from NVA.

4.7.1. References: Fitting Fee/Dispensing Fee

a) State Regulations “Fitting Fees.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.05. Office of the





Non-Covered Services

Participants who desire additional features non-covered by Medicaid due to not being medically necessary may pay for them separately. The Medicaid contractor will bill the

provider separately, and the provider may bill their usual and customary charge to the participant. If the participant cannot adapt to new lenses that were not originally covered by

Medicaid, the participant is responsible for any additional charges. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for

information on billing a participant.

4.8.1. References: Non-Covered Services

a) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,







5. Covered Services and Limitations: Examinations and Diagnostics

Idaho Medicaid requires the appropriate eye exam procedure code to be billed for routine eye exams. Instrument-based ocular screening (photo screening) may be used as part of a vision

exam but is not separately reimbursable unless performed by a physician or a non-physician practitioner. If the participant requests a copy of their prescription, it must be provided to the

participant. See Eligible Participants for age and plan restrictions.

Vision exams and testing are allowed once every 365 days without a prior authorization for participants under the age of twenty-one (21). Additional exams and testing must be prior

authorized by the Medical Care Unit. See Prior Authorization (PA) Requests for information on

submitting a request.

Examinations and vision testing are only covered for participants over twenty-one (21) when necessary to monitor a chronic medical condition that may damage the eye such as diabetes

or for acute conditions that, if left untreated, may cause permanent or chronic damage to the eye. A list of preapproved chronic and acute condition diagnosis codes is listed in Appendix A,

no prior authorization is necessary. A KX modifier must be used if an examination does not pertain to a preapproved diagnosis. Supporting medical documentation is required to be

attached to the claim.

References: Covered Services and Limitations: Examinations and Diagnostics

5.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.




Definitions, 42 U.S.C. §1396d(r)(2) (2016). Government Printing Office, https://www.govinfo.gov/content/pkg/USCODE-2017-title42/pdf/USCODE-2017-title42-

chap7-subchapXIX-sec1396d.pdf.




sec440-225.pdf.

5.1.2. Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,


“Attention Vision Providers; KX Modifier Use” MedicAide Newsletter, May 2013, https://www.idmedicaid.com/MedicAide%20Newsletters/May%202013%20MedicAide.pdf.










https://www.idmedicaid.com/MedicAide%20Newsletters/May%202013%20MedicAide.pdf





5.1.3. Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.

5.1.4. State Regulations “Eye Examinations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.01.a. Office


“Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06.


Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(ii) (2018). Idaho State Legislature,

https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.







New and Established Patient Exams A new patient is one who has not received any professional services for the last three (3) years from the physician or another physician of the same specialty who belongs to the same

group practice. An established patient is one who has received professional services within the last three (3) years.



Comprehensive Ophthalmological Services A comprehensive visual examination includes the following professional and technical vision services:

• Complete visual system examination; • Medical history review;

• General medical observation; • External and ophthalmoscopic examination;

• Determination of best-corrected visual acuity;

• Gross visual fields; • Basic sensorimotor examination with cycloplegia or mydriasis;

• Tonometry; • Refractive state;

• Initiation of diagnostic and treatment programs; and • Other examination techniques that may be included in the fee for the comprehensive

exam are: o Biomicroscopy;

o Corneal sensitivity;

o Corneal staining; o Fundus examination;

o Keratometry; o Retinoscopy;

o Slit lamp viewing, tear testing; and o Treatment programs.



Intermediate Ophthalmological Services

The participant is eligible for intermediate services if they do not require a comprehensive service for a routine eye exam or are being examined for a chronic, but stable, condition (i.e.,

known cataract). Intermediate Ophthalmological Services include medical examination and evaluation, with initiation or continuation of diagnostic and treatment program. This includes

the following: • Medical history review;

• General medical observations;

• External ocular and adnexal examination; • Diagnostic procedures such as ophthalmoscopy, biomicroscope and tonometry along

with a treatment regimen; and • Mydriasis.



Evaluation and Management Evaluation and Management (E/M) Codes are used to report services provided in the physician’s office related to eye injury or diseases affecting the eye. These codes do not

require a prior authorization. Providers are required to use either the 1995 or 1997 evaluation and management (E&M) documentation guidelines to document E&M office and outpatient

visits. Modifications to these guidelines include: • Elimination of the requirement to document the medical necessity of a home visit

instead of an office visit;

• Focusing documentation on changes and persisting problems since the last visit for established patients, provided the physician or non-physician practitioner indicate in

the record the patient’s medical record was reviewed and updated if necessary; and • Clarification that practitioners do not need to re-enter the participant’s chief complaint

and history into the medical record if ancillary staff or the participant have already updated it. The practitioner only needs to indicate in the medical record that the

information has been reviewed and verified.

5.5.1. References: Evaluation and Management

a) CMS Guidance 1995 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services,

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf.

1997 Documentation Guidelines for Evaluation and Management Services. Centers for

Medicare and Medicaid Services, Department of Health and Human Services,

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf.

Evaluation and Management Services. Centers for Medicare and Medicaid Services,

Department of Health and Human Services, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-

guide-ICN006764.pdf.

“Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule

(MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List.” MLN Matters

MM11063, November 2018, Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/Outreach-and-Education/Medicare-

Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf.

b) Idaho Medicaid Publications “2019 Evaluation and Management (E&M) Documentation Updates.” MedicAide Newsletter,

January 2019,

https://www.idmedicaid.com/MedicAide%20Newsletters/January%202019%20MedicAide.pdf.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf






https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11063.pdf

https://www.idmedicaid.com/MedicAide%20Newsletters/January%202019%20MedicAide.pdf

https://www.idmedicaid.com/MedicAide%20Newsletters/January%202019%20MedicAide.pdf



Fundus Photography Fundus examinations are included in the reimbursement for intermediate and comprehensive vision examinations. Fundus photography is not reimbursable by Idaho Medicaid for screening

purposes, or diagnosis of vision conditions such as myopia, hyperopia, or astigmatism. Photography is only separately reimbursable when monitoring potential progression of a

disease, or for guidance in evaluating the need for a specific treatment or intervention. If it will not guide future treatment, it is not medically necessary. When performed an

interpretation and report must be included in the medical record, regardless of a modifier 52.

5.6.1. References: Fundus Photography

a) Idaho Medicaid Publications “Attention Vision Providers: Fundus Photography, CPT 92250.” MedicAide Newsletter, March 2017,

https://www.idmedicaid.com/MedicAide%20Newsletters/March%202017%20MedicAide.pdf.

“Fundus Photography, CPT 92250.” MedicAide Newsletter, May 2018,

https://www.idmedicaid.com/MedicAide%20Newsletters/May%202018%20MedicAide.pdf.

“Medicaid Program Integrity Unit: Billing Fundus Photography.” MedicAide Newsletter, February 2018,

https://www.idmedicaid.com/MedicAide%20Newsletters/February%202018%20MedicAide.pdf.

https://www.idmedicaid.com/MedicAide%20Newsletters/March%202017%20MedicAide.pdf


https://www.idmedicaid.com/MedicAide%20Newsletters/February%202018%20MedicAide.pdf

https://www.idmedicaid.com/MedicAide%20Newsletters/February%202018%20MedicAide.pdf



Refraction Procedure Medicaid’s reimbursement rate for exams includes determination of refractive state and should be part of every intermediate or comprehensive exam. The Department will not pay

for an exam code and refraction code billed for the same date of service.

For participants under the age of 21, providers may bill a refraction (CPT® 92015) without the exam once a year. Determination of refractive state includes specification of lens type, lens

power, axis, prism, absorptive factor, impact resistance, interpupillary distance and other

necessary factors.



Tonometry Tonometry (CPT® 92100) is considered included within a comprehensive visual exam. If an additional separate tonometry is needed, Medicaid will allow one (1) additional tonometry

within the same 365-day period as the comprehensive exam. This limitation does not apply to participants receiving ongoing treatment for glaucoma.

5.8.1. References: Tonometry

a) State Regulations “Tonometry.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 502.03. Office of the





6. Covered Services and Limitations: Pharmaceuticals Optometrist and Ophthalmologist, with the appropriate credentials, are eligible for reimbursement for administering pharmaceuticals in an office setting through Gainwell

Technologies. Pharmaceuticals provided to participants for home-use must be billed through Magellan Healthcare. All pharmaceuticals must meet any coverage or criteria requirements to

be eligible for reimbursement.

References: Covered Services and Limitations: Pharmaceuticals

6.1.1. State Regulations “Board Certification of Optometrist Authorized to Obtain and Use Pharmaceutical Agents.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.600. Office of the


https://www.magellanhealthcare.com/magellan-of-idaho/




7. Covered Services and Limitations: Surgery and Procedures

Providers should follow the Physician and Non-Physician Practitioner, Idaho Medicaid Provider Handbook for criteria and billing requirements on surgeries. Optometrists also must follow the

Optometrists Performing Procedures section of this handbook.

https://www.idmedicaid.com/Provider%20Guidelines/Physician%20and%20Non-Physician%20Practitioner.pdf



Optometrists Performing Procedures In addition to those requirements optometrists must append modifier 55 to CPT® codes within the range 65XXX through 68XXX. This indicates that the optometrist provided post-op care

only. There are a limited number of codes that are within the full scope of the optometrist to provide that do not require a 55 modifier.

Codes for Optometrists That Do Not Require Modifier 55

CPT® Description

65205 Removal of foreign body, external eye; conjunctival superficial

65210 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral non-perforating

65220 Removal of foreign body, external eye; corneal, without slit lamp

65222 Removal of foreign body, external eye; corneal, with slit lamp

65430 Scraping of cornea, diagnostic, for smear and/or culture

65435 Removal of foreign body, intraocular; from anterior chamber of eye or lens

67700 Blepharotomy, drainage of abscess, eyelid

67820 Correction of trichiasis; epilation, by forceps only

67840 Excision of lesion of eyelid (except chalazion) without closure or with simple

direct closure

67850 Destruction of lesion of lid margin (up to 1 cm)

67938 Removal of embedded foreign body, eyelid

68020 Incision of conjunctiva, drainage of cyst

68040 Expression of conjunctival follicles (e.g., for trachoma)

68761 Closure of the lacrimal punctum; by plug, each

68801 Dilation of lacrimal punctum, with or without irrigation

68840 Probing of lacrimal canaliculi, with or without irrigation

7.1.1. References: Optometrists Performing Procedures

a) Idaho Medicaid Publications “Attention: Optometrists.” MedicAide Newsletter, April 2015,

https://www.idmedicaid.com/MedicAide%20Newsletters/April%202015%20MedicAide.pdf.

https://www.idmedicaid.com/MedicAide%20Newsletters/April%202015%20MedicAide.pdf



Blepharoplasty Idaho Medicaid covers blepharoplasty, surgery to remove excess tissue of the eyelids when medically necessary. Cosmetic blepharoplasty, which is performed to improve a patient’s

appearance, is considered is not covered. Medical necessary indications include procedures to improve abnormal function. Upper blepharoplasty or repair of blepharoptosis may be

considered functional in nature when excess upper eyelid tissue or the upper lid position produces functional complaints, such as impairments to the field of vision.

Participants must meet the Medicare criteria found in the Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) established by Medicare’s

contractor, Noridian Healthcare. Participants under the age of twenty-one may be eligible for additional coverage beyond the LCD criteria under Early and Periodic Screening, Diagnosis

and Treatment (EPSDT) guidelines with a prior authorization. EPSDT coverage may be available for cases where there is a deformity or trauma necessitating reconstruction.

7.2.1. References: Blepharoplasty

a) CMS Guidance Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift

(L36286). Noridian Healthcare Solutions. https://med.noridianmedicare.com/documents/10546/6990983/Blepharoplasty+Eyelid+Sur

gery+and+Brow+Lift+LCD/61353f20-a2dc-420b-9a70-542dd57db939.

b) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration,









sec440-225.pdf.

c) Idaho Medicaid Publications “Blepharoplasty Guidelines.” MedicAide Newsletter, November 2012,

https://www.idmedicaid.com/MedicAide%20Newsletters/November%202012%20MedicAide.

pdf.

d) State Regulations “Medical Necessity (Medically Necessary).” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,”

Sec. 011.16 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

https://med.noridianmedicare.com/documents/10546/6990983/Blepharoplasty+Eyelid+Surgery+and+Brow+Lift+LCD/61353f20-a2dc-420b-9a70-542dd57db939











https://www.idmedicaid.com/MedicAide%20Newsletters/November%202012%20MedicAide.pdf





Medical Assistance Program – Services to be Provided, Idaho Code 56-255(a) (2018). Idaho State Legislature,

https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Services Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.04 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan

Benefits,” Sec. 390.02(b) Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,







Corneal Transplants Idaho Medicaid may cover corneal transplants when efficacy has been demonstrated for the underlying condition. See the Organ Transplant section of the Hospital, Idaho Medicaid

Provider Handbook for information about coverage of corneal transplants and requirements.

https://www.idmedicaid.com/Provider%20Guidelines/Hospital.pdf



Lasik Eye surgeries for curing or alleviating myopia are non-covered by Idaho Medicaid. Lasik is not covered under Early and Periodic Screening, Diagnosis and Treatment (EPSDT) as it is not the

least costly option for alleviating the participant’s condition.

7.4.1. References: Lasik









sec440-225.pdf.

b) State Regulations



“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(m) Office of the Administrative Rules Coordinator, Division of













Photorefractive Keratectomy Eye surgeries for curing or alleviating myopia are non-covered by Idaho Medicaid. Photorefractive keratectomy is not covered under Early and Periodic Screening, Diagnosis and

Treatment (EPSDT) as it is not the least costly option for alleviating the participant’s condition

7.5.1. References: Photorefractive Keratectomy









sec440-225.pdf.

b) State Regulations



“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(m) Office of the Administrative Rules Coordinator, Division of













8. Covered Services and Limitations: Therapy Services Optometrists and Ophthalmologists are eligible providers of physical therapy services in their offices. Covered services must meet all occupational and physical therapy requirements to be

reimbursable.

References: Covered Services and Limitations – Therapy Services









sec440-225.pdf.

8.1.2. State Regulations “Payment Availability.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554.01. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


“Physical Therapy Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 502.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of

Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.












Eye Exercise Therapy See the Vision Therapy section.

Interactive Metronome Therapy See the Visual Processing Therapy section.



Vision Therapy According to the American Optometric Association (AOA), vision therapy is “a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the

doctor to develop, rehabilitate, and enhance visual skills and processing.” Exercises are usually weekly over several months performed in the optometric office and supplemented

with a prescribed concurrent at-home reinforcement program. The AOA also states that, “The vision therapy program is based on the results of a comprehensive eye examination or

consultation, and takes into consideration the results of standardized tests, the needs of the

patient, and the patient’s signs and symptoms. The use of lenses, prisms, filters, occluders,

specialized instruments, and computer programs are an integral part of vision therapy.”

8.4.1. Vision Therapy: Provider Qualifications Vision therapy is only reimbursable when administered by:

• An optometrist; or

• An occupational therapist or physical therapist that is; o Under the direct supervision of an optometrist;

o Trained in vision therapy by the supervising optometrist; and

o Following all requirements in the Therapy Services – Occupational and Physical, Idaho Medicaid Provider Handbook, including billing under their own or their

group NPI.

Direct supervision requires the optometrist to be physically available at the time and location of the services. Supervision of each therapist and each participant’s case must be

documented. The supervising optometrist should review each case at daily or weekly intervals, and the plan of care must be reviewed and updated by the supervising optometrist

as needed and at least every eight (8) weeks.

8.4.2. Vision Therapy: Eligible Participants Vision Therapy is excluded from coverage under IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” however, it may be available under the Children’s Medicaid program with a prior

authorization through EPSDT for children 7-21 years of age with a diagnosis of:

Diagnoses Covered for Vision Therapy

ICD-10-CM Description

H51.11—H51.12 Convergence insufficiency and excess

H52.521—H52.523 Paresis of accommodation

H52.531—H52.533 Spasm of accommodation

Diagnosis must be established with quantifiable measurements and symptoms. Vision therapy

is not considered a medically necessary treatment for asymptomatic conditions, autism, behavioral vision therapy, reading or learning disorders including, but not limited to dyslexia.

8.4.3. Vision Therapy: Coverage and Limitations Vision therapy is only reimbursable with a prior authorization, for an eligible participant when

provided by an eligible provider, and with adherence to all Medicaid requirements. All vision therapy services should be billed under CPT® 92065 (Orthoptic and pleoptic training). Therapy

is covered initially for one (1) hour per week for twelve (12) weeks, but more may be requested at the conclusion of the twelve (12) weeks with documentation of achieved progress

and continued need. Sessions are to be one-on-one for an hour each, but half hour sessions may be authorized if the participant is unable to tolerate a full hour of treatment.

https://www.idmedicaid.com/Provider%20Guidelines/Therapy%20Services%20-%20Occupational%20and%20Physical.pdf



A concurrent at-home reinforcement program is the standard of care and considered medically necessary for treatment to continue. The participant or their caregiver must keep a training

log. If the reinforcement program has not started by the second week of therapy, the provider must document the reason in the therapy record.

Only the following places of service are covered for vision therapy:

• 11 – Office; • 19 – Off Campus – Outpatient Hospital; and

• 22 – On Campus – Outpatient Hospital.

Vision therapy is not covered for group therapy, telehealth or with home computer programs.

At the end of the initial authorization if sufficient progress has not been achieved, requests for additional visits will be denied as other interventions, or a referral to an ophthalmologist,

may be more appropriate.

8.4.4. Vision Therapy: Additional Documentation Providers must maintain documentation as required in the General Information and

Requirements for Providers, Idaho Medicaid Provider Handbook. Additionally, documentation

must include: • Results from an exam/evaluation completed by the qualified optometrist;

• Convergence Insufficiency Symptom Survey results (>16), if available; • Baseline accommodative scores, if applicable;

• Baseline near point of convergence; • Baseline positive fusional vergence at near (PFV);

• An individualized plan of care that includes: o Qualified diagnosis and symptomology;

o Measurable short and long-term treatment goals;

o A plan to train the parents and child for a concurrent in-home exercise program;

and

o A review and update every eight weeks by the supervising optometrist with:

▪ Updated test results; and

▪ Progress toward treatment goals; • Treatment notes for each session that include:

o Date of treatment;

o Total time in minutes for treatment of CI or accommodation (time in and out); o Account of activity and results;

o Objective measurement of the participant’s response to the services; and o The name, signature and credentials of the person administering the therapy;

• Provider qualifications;

• Supervision documentation completed at daily or weekly intervals;

• If a scheduled session does not occur as scheduled, the provider must indicate in their

records the reason the plan of care was not followed; • Compliance with the concurrent at-home reinforcement program such as a daily log

signed and dated by an adult participant or caretaker; and

o If not started by the second week of therapy, the provider must document the

reason in the therapy record.

8.4.5. Vision Therapy: Prior Authorization (PA) Requests

Prior authorization request forms are available on the EPSDT webpage. Requests must be

submitted to [email protected] or faxed Attn: EPSDT Request to 1 (208) 364-



http://healthandwelfare.idaho.gov/Medical/Medicaid/EPSDT/tabid/3361/Default.aspx




1811. Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.

Requests may also be mailed to:

Attn: EPSDT Request

IDHW – Division of Medicaid P.O. Box 83720

Boise, ID 83720-0036

The status of a prior authorization request may be checked by providers online at the Gainwell

Technologies portal under “Authorization Status”, using your NPI.

Requests for prior authorization to initiate treatment should include: • A completed EPSDT Request Form;

• CPT® Code 92065 with prescribed amounts, frequency and duration; • Results from an exam/evaluation completed by the qualified optometrist within the

past three (3) months;

• Convergence Insufficiency Symptom Survey results (>16), if available; • Baseline accommodative scores if the child has one of the specified disorders of

accommodation; • Baseline near point of convergence;

• Baseline positive fusional vergence at near (PFV); • The diagnosis codes that qualify the child for vision therapy;

• The credentials of the person administering the therapy; and • An individualized plan of care that includes:

o Qualified diagnosis and symptomology;

o Measurable short and long-term treatment goals; and o A plan to train the parents and child for a concurrent in-home exercise program.

Requests for prior authorization to continue treatment after twelve (12) weeks should include:

• A completed EPSDT Request Form. • CPT® Code 92065 with prescribed amounts, frequency and duration;

• Current progress evaluation by supervising optometrist including updated test results, progress toward treatment goals, and confirmation of continuing medical

direction and evaluation;

• Documentation of compliance with the concurrent at-home reinforcement program such as a daily log signed and dated by an adult participant or caretaker; and

• Treatment notes for each session that include: o Date of treatment;

o Total time in minutes for treatment of CI or accommodation (time in and out); o Account of activity and results;

o The name and credentials of the person administering the therapy; and o Subject and objective narratives, if applicable; and

• Updated individualized plan of care.

8.4.6. References: Vision Therapy




https://sts.idmedicaid.com/Login.aspx?ReturnUrl=%2f%3fwa%3dwsignin1.0%26wtrealm%3dhttps%253a%252f%252fwww.idmedicaid.com%252f_trust%252f%26wctx%3dhttps%253a%252f%252fwww.idmedicaid.com%252f_layouts%252f15%252fAuthenticate.aspx%26wct%3d2019-05-22T17%253a07%253a00Z&wa=wsignin1.0&wtrealm=https%3a%2f%2fwww.idmedicaid.com%2f_trust%2f&wctx=https%3a%2f%2fwww.idmedicaid.com%2f_layouts%2f15%2fAuthenticate.aspx&wct=2019-05-22T17%3a07%3a00Z














b) Idaho Medicaid Publications “Attention: Vision Providers and Occupational Therapists.” MedicAide Newsletter, May 2014, https://www.idmedicaid.com/MedicAide%20Newsletters/May%202014%20MedicAide.pdf.

c) Idaho State Plan “Excluded Services.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment

3.1-A. Department of Health and Welfare, State of Idaho.

d) Professional Organizations “Definition of Optometric Vision Therapy.” American Optometric Association, April 2009,

https://www.aoa.org/Documents/CRG/definition-of-optometric-vision-therapy.pdf.

e) State Regulations “Excluded Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02.l. Office



“EPSDT Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 880—889. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


Medical Assistance Program — Services to Be Provided — Experimental Services or Procedures Excluded, Idaho Code 56-209d (2005). Idaho State Legislature,

https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-209d/.







https://www.aoa.org/Documents/CRG/definition-of-optometric-vision-therapy.pdf



https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-209d/



Visual Processing Therapy Visual Processing Therapy (VPT), or Interactive Metronome® therapy, is considered experimental and investigational by Idaho Medicaid and is a non-covered service. This

determination was made due to the lack of statistically significant research after a review of the literature. Services determined to be experimental and investigational are not eligible for

coverage through EPSDT.

8.5.1. Literature Review Beckelhimer et al. (2011)1 was a study of two stroke patients and the use of the interactive metronome in addressing motor performance. The study provides some preliminary evidence

suggesting efficacy of computer-based rhythm and timing in chronic stroke. However, the sample size was insufficient in this study to demonstrate applicability to any population. It

was not included in determining if visual processing therapy is a medically necessary service.

Shaffer et al. (2001)2 was a study of the effects of the interactive metronome on 56 boys age 6-12 with ADHD. Due to the lack of sample size this study was not acceptable for inclusion in

demonstrating visual processing therapy is a medically necessary service. The sample size

was insufficient to show applicability to a wider population. The study had additional issues that prevented it from adequately controlling for the placebo effect and too many variables

to allow demonstration of causation between the treatment and the benefits.

Park and Choi’s research (2017)3 was a case study of the effects of the interactive metronome on two male children ages four and six with ADHD. The sample size was insufficient in this

study to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.

Leisman and Melillo’s (2010)4 study of 109 male children 6-11 years of age addresses the apparent lack of motor coordinative abilities of ADHD. The sample size was insufficient in this

study to demonstrate applicability to the population, as well as harms and benefits from the treatment. The author’s conclusion was that a future large scale clinical trial would be

beneficial.

Gorman (2003)5 was not acceptable for inclusion due to being unpublished. Research must be peer-reviewed before it can be considered by Idaho Medicaid for inclusion in review.

Teicher (2019)6 was not acceptable for inclusion due to being unpublished. Research must be peer-reviewed before it can be considered by Idaho Medicaid for inclusion in review. The white

paper did state support for designation as an experimental/investigational service in that, “Research is ongoing and will continue to investigate and further define the host of

neurobiological changes associated with IM and BB training as well as their relationship to clinical outcome for individuals with ADHD.”

Roseblum and Regev (2013)7 was a study of the interactive metronome on 42 children ages

7-12 with developmental coordination disorders. The sample size was insufficient in this study

to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.

There is some low-quality evidence showing the possibility of benefit, however, the studies’

lack of applicable sample size and bias prevent them from supporting the service for being considered for coverage. The reviewed studies did not include a control group of individuals

not receiving the therapy or alternative treatments. Additional evidence-based and peer reviewed research is needed with adequately sized control and variable groups and long-term

evidence of benefits and harms before these therapies can be reconsidered for coverage.



8.5.2. References: Visual Processing Therapy

a) Idaho Medicaid Publications “Visual Processing Therapy.” MedicAide Newsletter, November 2020, https://www.idmedicaid.com/MedicAide%20Newsletters/November%202020%20MedicAide.

pdf.

b) Scholarly Work 1. “Computer-Based Rhythm and Timing Training in Severe, Stroke-Induced Arm

Hemiparesis” American Journal of Occupational Therapy, January-February 2011;

Vol. 65, No. 1, pages 96-100, Sarah C. Beckelhimer, Ann E. Dalton, Charissa A. Richter, Valerie Hermann, Stephen J. Page,

https://pubmed.ncbi.nlm.nih.gov/21309376/.

2. “Effect of interactive metronome training on children with ADHD.” American Journal of Occupational Therapy, March-April 2001; Vol. 55, No. 2, pages 155-162, R.J.

Shaffer, L.E. Jacokes, J.F. Cassily, S.I. Greenspan, R.F. Tuchman, P.J. Stemmer Jr.,


3. “Effects of interactive metronome training on timing, attention, working memory, and processing speed in children with ADHD: a case study of two children.” The

Journal of Physical Therapy Science, December 2017; Vol. 29, No. 12, pages 2165-2167, Yun-Yi Park, MSC, OT, Yu-Jin Choi, PhD, OT,


4. “Effects of motor sequence training on attentional performance in ADHD children.”

International Journal on Disability and Human Development, December 2010; Vol. 9, No. 4, Gary Leisman, Robert Melillo,

https://www.researchgate.net/publication/276038948_Effects_of_motor_sequence_training_on_attentional_performance_in_ADHD_children.

5. Gorman, Patrick (2003), Interactive Metronome – Underlying Neurocognitve

Correlates of Effectiveness. https://www.interactivemetronome.com/IMW/IMPublic/Research/Dr.Gormman%20N

EUROCOGNITVE%20CORRELATES%20OF%20EFFECTIVENESS%2002.pdf.

6. Teicher, Martin H., M.D., Ph.D (2019), White Paper: Profound Effects of Interactive

Metronome and Brain Balance Exercises on a Subset of Children with Attention Deficit Hyperactivity Disorder. Harvard Medical School,

https://creativehealthllc.com/wp-content/uploads/2019/11/Research_IM_ADHD_Harvard_Brain-Balance-and-

IM_White-Paper2019.pdf.

7. “Timing abilities among children with developmental coordination disorders (DCD) in

comparison to children with typical development.” Research in Developmental Disabilities, January 2013; Vol. 34, No. 1, pages 218-227, Sara Rosenblum, Noga

Regev, https://www.sciencedirect.com/science/article/abs/pii/S0891422212001783?via%3D

ihub/.



https://pubmed.ncbi.nlm.nih.gov/21309376/



https://www.researchgate.net/publication/276038948_Effects_of_motor_sequence_training_on_attentional_performance_in_ADHD_children

https://www.researchgate.net/publication/276038948_Effects_of_motor_sequence_training_on_attentional_performance_in_ADHD_children

https://www.interactivemetronome.com/IMW/IMPublic/Research/Dr.Gormman%20NEUROCOGNITVE%20CORRELATES%20OF%20EFFECTIVENESS%2002.pdf

https://www.interactivemetronome.com/IMW/IMPublic/Research/Dr.Gormman%20NEUROCOGNITVE%20CORRELATES%20OF%20EFFECTIVENESS%2002.pdf

https://creativehealthllc.com/wp-content/uploads/2019/11/Research_IM_ADHD_Harvard_Brain-Balance-and-IM_White-Paper2019.pdf







c) State Regulations “Medical Necessity (Medically Necessary).” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 011.16 Office of the Administrative Rules Coordinator, Division of Financial


“Experimental Treatments or Procedures.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.03 Office of the Administrative Rules Coordinator, Division of Financial


Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(a) (2018).

Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.

“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan

Benefits,” Sec. 390.02(g) Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,


“Vision Therapy.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec. 010.03









9. Documentation Requirements Documentation requirements applicable in specific situations are listed throughout the handbook for provider convenience. General documentation requirements are also required

and found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.




10. Prior Authorization Requests Information for requesting prior authorizations specific to eye and vision services is presented in the subsections below. Requirements specific to a service or item are listed throughout the

handbook for the provider’s convenience. General information about prior authorizations may be found in the General Billing Instructions, Idaho Medicaid Provider Handbook. Incomplete

or incorrectly filled out prior authorization requests will be denied for improper documentation by NVA or the Medical Care Unit.

Prior Authorization Requests: Medical Care Unit The Medical Care Unit reviews requests for vision exams that exceed limitations. The required

request form is available on the Medical Care Vision Services webpage. Completed request forms should be e-mailed to [email protected] or faxed to 1 (877) 314-8779.

Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.

The status of a prior authorization request for may be checked by providers online at the

Gainwell Technologies portal under “Authorization Status”, using your NPI. If there are questions regarding a denial, click on the notes, which will explain the reason for the denial.

Prior Authorization Requests: NVA National Vision Administrators (NVA) reviews prior authorization requests for glasses and

contact lenses. Prior authorizations, or prior approvals, are valid beginning the date they are received by NVA and are valid for two (2) months from the date of authorization. The required

request forms are available by logging into NVA’s website (www.e-nva.com). Requests should be submitted on NVA’s website or faxed to 1 (888) 483-6830. Requests must be faxed

individually for HIPAA compliance. Incomplete requests will be denied.

Requests may also be mailed to:

National Vison Administrators, L.L.C.

Attn: Idaho Medicaid Prior Approvals 1200 Route 46 West

Clifton, NJ 07013

Providers can view the outcome of the review by logging into their account at www.e-nva.com, or calling 1 (877) 626-2969.


http://healthandwelfare.idaho.gov/Medical/Medicaid/MedicalCare/Vision/tabid/694/Default.aspx






11. Reimbursement Providers must be enrolled to receive reimbursement from Idaho Medicaid. Idaho Medicaid reimburses medically necessary eye and vision services on a fee-for-service basis. Usual and

customary fees are paid up to the Medicaid maximum allowance listed in the Numerical Fee Schedule. Rates are set at 90% of the Medicare fee schedule when the code becomes covered

by Idaho Medicaid. Some participants may be responsible for a co-pay for services. NVA will bill Medicaid for any vision supplies.

See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding policy on

billing, prior authorization, and requirements for billing all other third-party resources before

submitting claims to Medicaid.

Participants who desire additional features non-covered by Medicaid may pay for them separately. The Medicaid contractor will bill the provider separately, and the provider may bill

their usual and customary charge to the participant. If the participant cannot adapt to new lenses that were not originally covered by Medicaid, the participant is responsible for any

additional charges. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for information on when billing a participant is allowable including

co-pays.

References: Reimbursement










Optometric Services, 42 C.F.R. Sec. 441.30 (1991). Government Printing Office,


11.1.2. Idaho Medicaid Publications “Attention: Optometrists, Podiatrists, and Chiropractors.” MedicAide Newsletter, October

2011, https://www.idmedicaid.com/MedicAide%20Newsletters/October%202011%20MedicAide.pd

f.

Co-Payments, Information Release MA11-26 (10/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho,

https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-26.pdf.

https://healthandwelfare.idaho.gov/Providers/Providers-Medicaid/MedicaidFeeSchedule/tabid/268/Default.aspx

https://healthandwelfare.idaho.gov/Providers/Providers-Medicaid/MedicaidFeeSchedule/tabid/268/Default.aspx












https://www.idmedicaid.com/MedicAide%20Newsletters/October%202011%20MedicAide.pdf

https://www.idmedicaid.com/MedicAide%20Newsletters/October%202011%20MedicAide.pdf




House Bill 260 Budget Reductions – Provider Payments, Information Release MA11-19




11.1.3. Idaho State Plan “Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid,

Attachment 4.19-B. Department of Health and Welfare, State of Idaho.

11.1.4. State Regulations “Payment Availability.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554. Office of

the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.

Provider Payment, Idaho Code 56-265 (2020). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-265/.

“Vision Services: Provider Reimbursement.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,”

Sec. 785. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.








Medicare Crossovers for Vision Services No prior authorization is necessary for Medicare recipients of covered services. The provider may supply products from any lab they choose and bill Medicare. If National Vision

Administrators (NVA) is used, NVA will bill Medicare for the provider. In both cases, the claim will automatically crossover to Medicaid, which will pay the co-insurance/deductible. Normally

Medicare allows more than Medicaid due to contract prices, so no additional payment may be made. For more information on third party recovery or third party liability, see the General

Billing Instructions, Idaho Medicaid Provider Handbook.





Third Party Insurance Billing Medicaid is the payer of last resort. If a Medicaid participant has other insurance for vision services, then the other insurance must be billed prior to billing Medicaid. Idaho Medicaid

does not require an explanation of benefits to be submitted for vision supplies ordered from Medicaid’s vision products contractor. NVA will deliver the requested supplies and bill the

third-party insurance. For more information on third party recovery or third party liability, see the General Billing Instructions, Idaho Medicaid Provider Handbook.

If the other insurance company requires an alternate provider of vision hardware, the participant must choose between the Medicaid product and the non-Medicaid product.

Medicaid will not provide reimbursement for the non-Medicaid product. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for

information on when billing a participant is allowable.






Appendix A. Preapproved Diagnoses for Chronic and Acute Conditions

The following ICD-10-CM diagnosis codes have been identified by the Department as

indicating a covered chronic condition requiring periodic vision exams or an acute condition

that may damage the eye. Diagnosis codes that are unspecified for which eye is affected

within the listed ranges are not covered.

Preapproved Diagnoses for Chronic and Acute Conditions


A18.51 – A18.59 Tuberculous of eye

B00.50 – B00.59 Herpesviral ocular disease

B02.30 – B02.39 Zoster ocular disease

B60.12 Conjunctivitis due to Acanthamoeba

B60.13 Keratoconjunctivitis due to Acanthamoeba

C71.0 – C71.9 Malignant neoplasm of brain

D31.0 – D31.92 Benign neoplasm of eye and adnexa

D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency

D86.0 – D86.9 Sarcoidosis

E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm

E08.00 – E08. 9 Diabetes mellitus due to underlying condition

E09.00 – E09.9 Drug or chemical induced diabetes mellitus

E10.10 – E10.9 Type 1 diabetes mellitus

E11.00 – E11.9 Type 2 diabetes mellitus

E13.00 – E13.9 Other specified diabetes mellitus

E78.00 – E78.01 Pure hypercholesterolemia

G24.5 Blepharospasm

G30.0 – G30.9 Alzheimer's disease

G31.01 – G31.1 Frontotemporal dementia

G35 Multiple sclerosis

G36.0 Neuromyelitis optica [Devic]

G43.109 Migraine with aura, not intractable, without status migrainosus

G43.609 Persistent migraine aura with cerebral infarction, not

intractable, without status migrainosus

G45.3 Amaurosis fugax

G91.0 – G91.3 Hydrocephalus

G91.8 Other hydrocephalus

G91.9 Hydrocephalus, unspecified

G93.2 Benign intracranial hypertension

G93.7 Reye's syndrome

H00.011 – H00.19 Hordeolum (externum) (internum) of eyelid

H01.001 – H01.9 Blepharitis





H02.001 – H02.9 Other disorders of eyelid

H04.001 – H04.9 Disorders of lacrimal system

H05.00 – H05.9 Disorders of orbit

H10.011 – H10.9 Conjunctivitis

H11.001 – H11.9 Other disorders of conjunctiva

H15.001 – H15.9 Scleritis

H16.001 – H16.9 Keratitis

H17.00 – H17.9 Corneal scars and opacities

H18.001 – H18.9 Other disorders of cornea

H20.00 – H20.9 Iridocyclitis

H21.00 – H21.9 Other disorders of iris and ciliary body

H22 Disorders of iris and ciliary body in diseases classified

elsewhere

H25.011 – H25.9 Age-related cataract

H26.001 – H26.9 Other cataract

H27.00 – H27.9 Other disorders of lens

H28 Cataract in diseases classified elsewhere

H30.001 – H30.93 Chorioretinal inflammation

H31.001 – H31.9 Other disorders of choroid

H32 Chorioretinal disorders in diseases classified elsewhere

H33.001 – H33.8 Retinal detachments and breaks

H34.00 – H34.9 Retinal vascular occlusions

H35.00 – H35.9 Other retinal disorders

H36 Retinal disorders in diseases classified elsewhere

H40.001 – H40.9 Glaucoma

H42 Glaucoma in diseases classified elsewhere

H43.00 – H43.9 Disorders of vitreous body

H44.001 – H44.9 Disorders of globe

H46.00 – H46.9 Optic neuritis

H47.011 – H47.9 Other disorders of optic [2nd] nerve and visual pathways

H49.00 – H49.43 Paralytic strabismus

H49.881 – H49.9 Other paralytic strabismus

H50.00 – H50.9 Other strabismus

H51.0 – H51.9 Other disorders of binocular movement

H53.10 – H53.139 Subjective visual disturbances, transient or sudden visual loss

H53.15 – H53.489 Visual disturbances

H53.60 – H53.9 Night blindness, vision sensitivity deficiencies, other or unspecified visual disturbances

H54.0 – H54.2X22 Blindness and low vision

H54.40 – H54.52A2 Blindness and low vision, one eye

H55.00 – H55.89 Nystagmus and other irregular eye movements





H57.00 – H57.9 Other disorders of eye and adnexa

H59.331 – H59.43 Intraoperative and postprocedural complications and

disorders of eye and adnexa, not elsewhere classified

I69.998 Other sequelae following unspecified cerebrovascular

disease

K26.0 Acute duodenal ulcer with hemorrhage

K50.90 – K50.919 Crohn's disease, unspecified

K51.00 – K51.919 Ulcerative colitis

L40.50 – L40.59 Arthropathic psoriasis

M02.30 – M02.39 Reiter's disease

M05.00 – M05.9 Rheumatoid arthritis with rheumatoid factor

M06.00 – M06.9 Other rheumatoid arthritis

M08.00 – M08.09 Unspecified juvenile rheumatoid arthritis

M08.20 – M08.99 Juvenile arthritis

M12.00 – M12.09 Chronic post rheumatic arthropathy [Jaccoud]

M32.0 – M32.9 Systemic lupus erythematosus (SLE)

M34.0 – M34.9 Systemic sclerosis [scleroderma]

M35.00 – M35.09 Sicca syndrome [Sjogren]

M35.2 Behcet's disease

N18.1 – N18.9 Chronic kidney disease

Q01.0 – Q01.9 Encephalocele

Q02 Microcephaly

Q03.0 – Q03.9 Congenital hydrocephalus

Q04.0 – Q04.6 Other congenital malformations of brain

Q05.0 – Q05.9 Spina bifida

Q07.00 – Q07.03 Arnold-Chiari syndrome

Q10.0 – Q10.7 Congenital malformations of eyelid, lacrimal apparatus and orbit

Q11.0 – Q11.3 Anophthalmos, microphthalmos and macrophthalmos

Q12.0 – Q12.9 Congenital lens malformations

Q13.0 – Q13.9 Congenital malformations of anterior segment of eye

Q14.0 – Q14.9 Congenital malformations of posterior segment of eye

Q15.0 – Q15.9 Other congenital malformations of eye

Q85.00 Neurofibromatosis, unspecified

Q85.01 Neurofibromatosis, type 1

Q85.03 Schwannomatosis

Q85.09 Other neurofibromatosis

R44.1 Visual hallucinations

R48.3 Visual agnosia

R73.03 Prediabetes

S00.201A – S00.279S Other and unspecified superficial injuries of eyelid and

periocular area





S02.101A – S02.109S Unspecified fracture of base of skull

S02.11AA – S02.11HS Fracture of occiput

S02.121A – S02.122S Fracture of orbital roof

S02.30XA – S02.32XS Fracture of orbital floor

S02.40AA – S02.40FS Malar fracture and Zygomatic fracture

S02.601A – S02.602S Fracture of unspecified part of body of mandible

S02.610A – S02.652S Fracture of condylar process, subcondylar process, coronoid process, angle, or ramus of mandible

S02.670A – S02.672S Fracture of alveolus of mandible

S02.80XA – S02.82XS Fracture of other specified skull and facial bones

S02.831A – S02.832S Fracture of medial orbital wall

S02.841A – S02.842S Fracture of lateral orbital wall

S02.85XA – S02.85XS Fracture of orbit, unspecified

S03.00XA – S03.03XS Dislocation of jaw

S05.00XA – S05.02XS Injury of conjunctiva and corneal abrasion without foreign

body

S05.90XA – S05.90XS Unspecified injury of unspecified eye and orbit

T15.01XA – T15.01XS Foreign body in cornea, right eye

T15.02XA – T15.02XS Foreign body in cornea, left eye

T15.11XA – T15.11XS Foreign body in conjunctival sac, right eye

T15.12XA – T15.12XS Foreign body in conjunctival sac, left eye

T15.81XA – T15.81XS Foreign body in other and multiple parts of external eye,

right eye

T15.82XA – T15.82XS Foreign body in other and multiple parts of external eye, left eye

T85.21XA – T85.398S Mechanical complication of intraocular lens or other ocular

prosthetic device

T86.8401 – T86.8403 Corneal transplant rejection

T86.8411 – T86.8413 Corneal transplant failure

T86.8421 – T86.8423 Corneal transplant infection

T86.8481 – T86.8483 Other complications of corneal transplant

T86.8491 – T86.8493 Unspecified complication of corneal transplant

Y77.11 Contact lens associated with adverse incidents

Z79.3 Long term use of hormonal contraceptives

Z79.891 Long term (current) use of opiate analgesic

Z79.899 Other long term (current) drug therapy

Z96.1 Presence of intraocular lens

a) References: Preapproved Diagnoses for Chronic and Acute Conditions

i) Idaho Medicaid Publications



“Eye and Vision Services New Preapproved Diagnoses.” MedicAide Newsletter, December 2020,

https://www.idmedicaid.com/MedicAide%20Newsletters/December%202020%20MedicAide.pdf.

“Eye and Vision Services New Preapproved Diagnoses.” MedicAide Newsletter, November

2020, https://www.idmedicaid.com/MedicAide%20Newsletters/November%202020%20MedicAide.

pdf.

https://www.idmedicaid.com/MedicAide%20Newsletters/December%202020%20MedicAide.pdf

https://www.idmedicaid.com/MedicAide%20Newsletters/December%202020%20MedicAide.pdf




Effective 01/20/2020 National Vision Administrators, L.L.C. Page 71 of 149

Idaho Frame Brochure

Appendix B. Frame Brochure for Idaho Medicaid Vision Products

National Vision Administrators, L.L.C. 1200 Route 46 West, Clifton, NJ 07013

Telephone: (877) 626-2969 www.e-nva.com





a) V2020 Child Frame List

V2020 Child Frame List

Frame Name Manufacturer Material

7710 Capri Optics Metal


14th Avenue Limited Editions Plastic


Active Modern Optical Plastic

Adam Modern Optical Plastic

Adorable Modern Optical Plastic

Amber Modern Optical Plastic

Anne Modern Optical Plastic

Answer Modern Optical Plastic

Aries Modern Optical Metal

Attitude 18 Zimco Optics Plastic

Banzai Modern Optical Metal

Bashful Modern Optical Plastic

Beth Modern Optical Metal

Bicycle Modern Optical Plastic

Brave Modern Optical Plastic

Buzz Modern Optical Plastic

Candia Limited Editions Plastic

Capricorn Modern Optical Metal

Care Modern Optical Plastic

Caribbean Zimco Optics Metal

Catchy Modern Optical Plastic

Certain Modern Optical Plastic

Cheerful Modern Optical Metal

Chelsea Zimco Optics Metal

Chill Modern Optical Plastic

Chris Modern Optical Plastic

Climb Modern Optical Plastic

Clout Modern Optical Plastic

Clutch Modern Optical Plastic

Compliment Modern Optical Plastic

Concert Modern Optical Plastic

Confetti Modern Optical Plastic

Connie Modern Optical Plastic

Cosmo Modern Optical Plastic

Cutie Modern Optical Metal

Cyclone Modern Optical Metal,

Rimless Dawn Modern Optical Metal

Dazzle Modern Optical Metal

Degree Modern Optical Plastic






Dillon Modern Optical Plastic

Doug Modern Optical Metal

Downtown Limited Editions Plastic

Dynamite Modern Optical Metal

Emma Modern Optical Plastic

EQ301 Eye Q Plastic

EQ313 Eye Q Plastic

Equal Modern Optical Plastic

Exclusive 120 Continental Optics Metal


Falcon Modern Optical Plastic

Feline Modern Optical Plastic

Finale Modern Optical Metal

Finesse Modern Optical Metal

Floral Modern Optical Plastic

Forbidden Modern Optical Plastic

Freedom Modern Optical Plastic

Fregossi 368 Continental Optics Plastic

Gemini Modern Optical Metal

Genius Modern Optical Plastic

Gift Modern Optical Plastic

Goodies Modern Optical Plastic

Hannah Modern Optical Plastic

Harper Modern Optical Plastic

Hector Modern Optical Plastic

Hide & Seek Modern Optical Metal

Holiday Modern Optical Plastic

Hudson Zimco Optics Metal

Icon Modern Optical Metal

Incognito Modern Optical Plastic

J4154 (Blvd 4154) New York Eye Metal

Jazz Modern Optical Metal

Judi Modern Optical Plastic

Keynote Modern Optical Metal

Kody Modern Optical Metal

L6001 Lantis Plastic




L6005 Lantis Metal

L6006 Lantis Metal

L6007 Lantis Metal


L6009 Lantis Metal

L6010 Lantis Metal

L6011 Lantis Metal

L6012 Lantis Metal









L7001 Lantis Metal


L7003 Lantis Metal

L7004 Lantis Metal

L7005 Lantis Metal




L7010 Lantis Metal

L7011 Lantis Metal

L7012 Lantis Metal




L8001 Lantis Metal


L8003 Lantis Metal

L8004 Lantis Metal

L8005 Lantis Metal



L8008 Lantis Metal

L8009 Lantis Metal

L8010 Lantis Metal

L8011 Lantis Metal

L8012 Lantis Metal









L8021 Lantis Metal

L8022 Lantis Metal

L8023 Lantis Metal

L8024 Lantis Metal






Launch Modern Optical Plastic






LG 1050 Hart Specialties Plastic

Lilac Capri Optics Metal

Lollipop Cable Modern Optical Metal

Lollipop Skull Modern Optical Metal

LTD 181 Limited Editions Metal

Lulu Modern Optical Plastic

Mainstreet 415 Hart Specialties Plastic

Manhattan Limited Editions Plastic

Media Modern Optical Plastic

Metropolitan Modern Optical Plastic

Mingle Modern Optical Plastic

Monaco Zimco Optics Metal

Neon Modern Optical Plastic

Ninja Modern Optical Metal

Now Modern Optical Plastic

Parallel Modern Optical Plastic

Patches Modern Optical Plastic

Patience Modern Optical Plastic

Pixie Modern Optical Plastic

Plasma Modern Optical Plastic

Pleasure Modern Optical Plastic

Precise Modern Optical Plastic

PT 48 Capri Optics Metal









Pumpkin Cable Modern Optical Metal

Pumpkin Skull Modern Optical Metal

Ralph Modern Optical Plastic

Randi Modern Optical Metal

Rigid Modern Optical Plastic

Rori Modern Optical Plastic

S310 Zimco Optics Plastic




Sadie Modern Optical Plastic

Score Modern Optical Plastic

Sheer Modern Optical Plastic

Skippy Modern Optical Plastic

Sky Modern Optical Plastic

Slick Modern Optical Plastic






Slide Modern Optical Metal

Sneakers Modern Optical Plastic

Special Modern Optical Metal

Speckle Modern Optical Plastic

Splash Modern Optical Plastic

Sporty Modern Optical Plastic

Spunky Modern Optical Plastic

Storm Modern Optical Plastic

Structure Modern Optical Plastic

Studio Modern Optical Plastic

SW 319 Eye Q Plastic



Swift Modern Optical Metal

Swirl Modern Optical Plastic

Tackle Modern Optical Plastic

Tactic Modern Optical Metal

Takeoff Modern Optical Plastic

Tender Modern Optical Plastic

Theory Modern Optical Plastic

Thrive Modern Optical Plastic

Tie-Dye Modern Optical Plastic

Tigress Modern Optical Plastic

Todd Modern Optical Metal

Tomorrow Modern Optical Plastic

Tori Modern Optical Plastic

Tornado Modern Optical Plastic

U 14 Capri Optics Plastic











UM 70 Capri Optics Plastic


Unite Modern Optical Plastic

Uptown Limited Editions Plastic

Urban Modern Optical Plastic

US 53 Capri Optics Plastic















Vern Modern Optical Metal

Visa Modern Optical Plastic

Whimsy Modern Optical Metal

Wiggle Modern Optical Plastic

Windy Modern Optical Plastic

Wow Modern Optical Plastic

Yippee Modern Optical Plastic




b) V2025 Child Frame List



+ Baby 1 Miraflex Plastic

+ Baby Lux Miraflex Plastic

+ Baby Zero Miraflex Plastic

+ New Baby 1 Miraflex Plastic



Baby Lux Miraflex Plastic

Baby Lux 2 Miraflex Plastic

Baby One Miraflex Plastic

Baby One 2 Miraflex Plastic

Baby Plus Miraflex Plastic

Baby Plus 2 Miraflex Plastic

Baby Zero Miraflex Plastic

Baby Zero 2 Miraflex Plastic

Beginner Modern Optical Plastic

Brian Capri Optics TR90

Eva Miraflex Plastic

FX 3 Capri Optics Titanium Memory Metal




FX20 Capri Optics Titanium Memory Metal





Maxi Baby Miraflex Plastic

Maxi Baby 2 Miraflex Plastic

Mayan 1 Miraflex Plastic



Mini Baby Miraflex Plastic

Model 1 Specs4Us (Erin's World) Metal




















New Baby 1 Miraflex Plastic




Nicki 48 Miraflex Plastic

Nick 50 Miraflex Plastic


Split A Capri Optics TR90

Split C Capri Optics TR90

T 18 Capri Optics TR90



Youth Capri Optics TR90




c) V2020 Adult Frame List

V2020 Adult Frame List







Adorable Modern Optical Plastic

Agree Modern Optical Plastic




Appeal Modern Optical Plastic


Attitude 18 Zimco Optics Plastic




Bria Modern Optical Metal


Camille Modern Optical Metal


Capricorn Modern Optical Metal

Caribbean Zimco Optics Metal






Compliment Modern Optical Plastic




Cyclone Modern Optical Metal,

Rimless Dance Modern Optical Plastic



Diana Modern Optical Metal



Downtown Limited Editions Plastic

Eileen Modern Optical Plastic


EQ301 Eye Q Plastic






EQ313 Eye Q Plastic


Ethel Modern Optical Metal








Forbidden Modern Optical Plastic

Freedom Modern Optical Plastic

Fregossi 368 Continental Optics Plastic



Glenn Modern Optical Metal

Gloria Modern Optical Metal



Heat Modern Optical Metal




Ivy Capri Optics Metal

J4154 (BLVD 5154) New York Eye Metal

James Modern Optical Metal

Jazz Modern Optical Metal

Joseph Modern Optical Metal


Karma Modern Optical Plastic

Keith Modern Optical Metal

Keynote Modern Optical Metal






L6005 Lantis Metal

L6006 Lantis Metal

L6007 Lantis Metal


L6010 Lantis Metal

L6011 Lantis Metal

L6012 Lantis Metal









L7001 Lantis Metal


L7003 Lantis Metal

L7004 Lantis Metal

L7005 Lantis Metal




L7009 Lantis Metal

L7010 Lantis Metal

L7011 Lantis Metal

L7012 Lantis Metal






L8021 Lantis Metal

L8023 Lantis Metal

L8024 Lantis Metal






Lisa Modern Optical Metal

Liz Zimco Optics Metal



Manhattan Limited Editions Plastic


Metropolitan Modern Optical Plastic


Monica Modern Optical Plastic

Moscow Zimco Optics Metal

Nancy Modern Optical Metal


Overlook Zimco Optics Metal

Overview Modern Optical Plastic

Pacific Zimco Optics Metal



Phase Modern Optical Plastic

















Relax Modern Optical Plastic






Sadie Modern Optical Plastic






Structure Modern Optical Plastic

Studio Modern Optical Plastic







TedCC Modern Optical Metal





Tomorrow Modern Optical Plastic













UL 90 Capri Optics Plastic





















Vern Modern Optical Metal







d) V2025 Adult Frame List























Nicki 48 Miraflex Plastic







e) V2020 Frames Listed by Size

V2020 Frames Listed by Size

Style Material Sizes

Cutie Metal 32-15-115; 35-15-120

Mainstreet 415 Plastic 33-20-115; 36-20-120; 39-20-125

L8005 Metal 36-17-140; 38-17-140; 40-18-140

Lollipop Skull Metal 39-20-120; 41-20-125; 43-20-125

Lollipop Cable Metal 39-20-130; 41-20-135; 43-20-140

Pumpkin Skull Metal 40-16-120; 42-16-125

Wiggle Plastic 40-16-120; 42-16-125; 44-16-130

Pumpkin Cable Metal 40-16-130; 42-16-135

Cheerful Metal 40-18-120; 42-18-125; 44-18-130

Dawn Metal 41-16-120; 43-16-125; 45-16-130

Windy Plastic 41-17-120; 43-17-125

Care Plastic 42-15-125; 44-15-130; 46-15-135

L8018 Plastic 42-16-128; 45-16-130

Bashful Plastic 42-16-130

PT 84 Metal 42-17-125; 45-17-130; 48-19-135

L8011 Metal 42-18-120

Sneakers Plastic 42-18-125; 45-18-130; 47-18-135

Dynamite Metal 42-18-130; 45-18-135; 47-18-140

Hide & Seek Metal 42-19-125; 44-19-143

Whimsy Metal 43-17-120; 45-17-125

LTD181 Metal 43-20-130; 46-20-135; 49-20-140; 52-20-145

Score Plastic 44-15-130; 46-15-135

Tori Plastic 44-15-130; 46-15-135

L8030 Plastic 44-16-125

PT 67 Metal 44-16-125

Randi Metal 44-16-125; 46-16-130

Skippy Plastic 44-16-125; 46-16-130

Sporty Plastic 44-17-125; 46-17-130

Speckle Plastic 44-17-130; 46-17-135

US 78 Plastic 44-17-130; 47-17-135

L8001 Metal 44-18-125

Ninja Metal 44-18-130; 46-18-135

L8008 Metal 44-19-130

L8019 Plastic 45-13-128






L8006 Plastic 45-15-128

Bicycle Plastic 45-15-130; 47-15-135

Confetti Plastic 45-16-125

L8016 Plastic 45-16-127

Climb Plastic 45-16-130

Goodies Plastic 45-16-130

Tackle Plastic 45-16-130; 47-16-135

L8015 Plastic 45-17-126

Tie-Dye Plastic 45-17-130; 47-17-135

Patches Plastic 45-18-130

L8010 Metal 45-19-125

Neon Plastic 45-19-140

L8002 Plastic 46-15-125

L8027 Plastic 46-15-130

US 55 Plastic 46-15-130

L8020 Plastic 46-16-135; 48-14-128

L8017 Plastic 46-17-130

L8029 Plastic 46-17-130

L8012 Metal 46-18-125

L8009 Metal 46-18-130

Splash Plastic 46-18-130; 48-18-135

Todd Metal 46-18-135; 48-18-140; 50-18-145

Special Metal 46-20-130; 48-20-135; 50-20-140

L8022 Metal 47-15-130

Adorable Plastic 47-15-135

L8013 Plastic 47-16-130

Spunky Plastic 47-16-130

L8007 Plastic 47-16-130; 49-16-130

L8004 Metal 47-17-130

Sky Plastic 47-17-130; 49-17-135

Gift Plastic 47-17-135; 49-17-140

Takeoff Plastic 47-17-135; 49-17-140

5th Avenue Plastic 47-17-140

Gemini Metal 47-18-135

Incognito Plastic 47-18-135






J4154 (Formerly

Boulevard 4154)

Metal 47-18-135; 50-18-140

Tender Plastic 47-19-130

Banzai Metal 47-19-135

Capricorn Metal 47-20-135; 49-20-140

7712 Metal 47-20-140

Falcon Plastic 47-20-140

Hudson Metal 47-20-140

Genius Plastic 47-21-140

L8026 Plastic 48-15-130

L8014 Plastic 48-16-130; 50-16-130

L8024 Metal 48-16-130

Pixie Plastic 48-16-130

14th Avenue Plastic 48-16-135

L8023 Metal 48-16-135

Storm Plastic 48-16-140

L8028 Plastic 48-17-130

Anne Plastic 48-17-135; 50-17-140

L8003 Metal 48-17-135

SW319 Plastic 48-17-140

L6009 Metal 48-18-125

Certain Plastic 48-18-130; 50-18-135

Chelsea Metal 48-18-135

Downtown Plastic 48-18-140

Forbidden Plastic 48-18-140

Monaco Metal 48-18-140

U 14 Plastic 48-18-140

U 40 Plastic 48-18-140

U 205 Plastic 48-18-140

Finale Metal 48-19-135; 50-19-140; 52-19-145

Slide Metal 48-20-135

Aries Metal 48-20-140; 50-20-145

S325 Plastic 48-20-140

U 23 Plastic 48-20-140






Cosmo Plastic 48-20-145; 50-20-150; 52-22-150; 54-22-150; 50-22-150; 52-24-150; 54-24-150

LG 1050 Plastic

48-20-145; 50-20-150; 52-20-150; 54-20-150; 56-22-150;

50-22-150; 52-22-150; 54-22-150; 56-24-150; 52-24-150;

54-24-150

U 208 Plastic 49-15-140

L6010 Metal 49-16-130

Wow Plastic 49-16-135; 51-16-140

Attitude 18 Plastic 49-17-135

Finesse Metal 49-17-135

Slick Plastic 49-17-135; 51-17-140; 54-17-145; 57-17-150; 60-17-150

Rigid Plastic 49-17-140

L6012 Metal 49-18-130

Lilac Metal 49-18-130; 51-18-135

Ethel Metal 49-18-135; 52-18-140; 55-18-140

PT 87 Metal 49-18-135

Sadie Plastic 49-18-135

U 203 Plastic 49-18-135; 52-18-140

Yippee Plastic 49-18-135

S323 Plastic 49-19-135

Dazzle Metal 49-20-135; 51-20-140; 53-20-145

Brave Plastic 50-15-135; 52-15-140

U 33 Plastic 50-15-140

Lulu Plastic 50-16-135

Judi Plastic 50-16-135; 53-16-140

L6004 Plastic 50-16-138; 52-16-135

Freedom Plastic 50-16-140

Candia Plastic 50-17-130; 52-17-135

L8021 Metal 50-17-130

Monica Plastic 50-17-130; 52-17-135; 54-17-140

Structure Plastic 50-17-130; 52-17-135

Connie Plastic 50-17-135; 52-17-140

Rori Plastic 50-17-135

Catchy Plastic 50-17-140; 52-17-145

Manhattan Plastic 50-17-140

L6011 Metal 50-18-130

Beth Metal 50-18-135; 52-18-140






Fregossi 368 Plastic 50-18-135

PT 86 Metal 50-18-135

7710 Metal 50-18-140

U 21 Plastic 50-18-145

L7005 Metal 50-19-135

Cyclone Metal 50-19-140

Equal Plastic 50-19-140

Harper Plastic 50-19-140

Dillon Plastic 50-19-140; 52-19-145; 54-19-150

Relax Plastic 50-19-140

Swift Metal 50-19-140; 52-19-145

U 32 Plastic 50-19-140

Heat Metal

Rimless 50-20-140

Chris Plastic 50-20-140; 52-20-145

Theory Plastic 50-21-140

Overview Plastic 50-22-145

Overlook Metal 50-24-140

Sheer Plastic 51-15-140

Swirl Plastic 51-16-135

Active Plastic 51-16-140

Adam Plastic 51-16-140; 53-16-145

Amber Plastic 51-16-140

Hannah Plastic 51-16-140

Plasma Plastic 51-16-140; 53-16-145

L6008 Plastic 51-17-130

Degree Plastic 51-17-135

Keynote Metal 51-17-135

SW444 Plastic 51-17-135

US 67 Plastic 51-17-135

US 74 Plastic 51-17-135; 53-17-140

Tomorrow Plastic 51-17-135; 53-17-140; 55-17-145

Floral Plastic 51-17-140

Chill Plastic 51-17-140

U 39 Plastic 51-17-140

Unite Plastic 51-17-140






Urban Plastic 51-17-140

US 75 Plastic 51-17-140; 54-17-145

US 80 Plastic 51-17-140; 54-17-145

L7012 Metal 51-18-135

PT 80 Metal 51-18-135; 53-18-140

UL 90 Plastic 51-18-135

US 56 Plastic 51-18-135

Launch Plastic 51-18-140

Emma Plastic 51-18-140

Hector Plastic 51-18-140

Precise Plastic 51-18-140

Uptown Plastic 51-18-145

L6005 Metal 51-19-130

Camille Metal 51-19-135

Icon Metal 51-19-135; 53-19-140

Caribbean Metal 51-19-140

Exclusive 157 Metal 51-19-140

Feline Plastic 51-19-140

Studio Metal 51-19-140

US 53 Plastic 51-19-140

Appeal Plastic 51-20-140

L6002 Plastic 52-14-130

Answer Plastic 52-15-140

SW445 Plastic 52-15-140

L6001 Plastic 52-16-130; 54-16-135

L6003 Plastic 52-16-130; 54-16-135

L6017 Plastic 52-16-135

Agree Plastic 52-16-140

EQ313 Plastic 52-16-140

S-310 Plastic 52-16-140

S-313 Plastic 52-16-140

Tigress Plastic 52-16-140

Lisa Metal 52-17-135; 55-17-140

EQ301 Plastic 52-17-140

Ralph Plastic 52-17-140; 54-17-145; 56-17-150

L6018 Plastic 52-17-145






L7017 Plastic 52-17-145

Phase Plastic 52-17-145

Diana Metal 52-18-135

L6006 Metal 52-18-135

L7004 Metal 52-18-135

Nancy Plastic 52-18-135

Clutch Plastic 52-18-140

Jazz Metal 52-18-140; 54-18-145; 56-18-150; 58-18-155; 60-18-155

Kody Metal 52-18-140; 54-18-145

L7015 Plastic 52-18-140

Pleasure Plastic 52-18-140

Thrive Plastic 52-18-140

U 36 Plastic 52-18-140

Tornado Plastic 52-18-140; 54-18-145; 56-18-150

L7003 Metal 52-19-140

Ted CC Metal 52-19-165; 54-19-170

Vern Metal 52-20-135; 54-20-140

UL 91 Plastic 52-20-140

Doug Metal 52-20-140; 54-20-145; 56-20-145

UM 70 Plastic 52-22-140; 54-22-145

Now Plastic 53-15-140

L7007 Plastic 53-15-145; 55-17-145

Bria Metal 53-16-135

Compliment Plastic 53-16-135

L7002 Plastic 53-16-138; 55-16-140

Dance Plastic 53-16-140

Liz Metal 53-16-140

PT 56 Metal 53-16-140; 55-16-145

Clout Plastic 53-16-145

L6016 Plastic 53-17-135

L7008 Plastic 53-17-135

Concert Plastic 53-18-135

Mingle Plastic 53-18-135

Pacific Metal 53-18-135

L6007 Metal 53-18-138

Exclusive 120 Metal 53-18-140; 55-18-145






Glenn Metal 53-18-140; 55-18-145

Tactic Metal 53-18-140

US 73 Plastic 53-18-145; 55-18-150

Metropolitan Plastic 53-18-150

Parallel Plastic 53-20-145

Patience Plastic 54-14-140

Keith Metal 54-16-140; 56-16-145; 58-16-150

Media Plastic 54-16-140

Moscow Metal 54-16-140; 56-18-145; 58-18-150

Buzz Plastic 54-16-145

Holiday Plastic 54-17-140

Visa Plastic 54-17-140

L7001 Metal 54-18-138

UM 73 Plastic 54-18-140; 56-18-145

L7011 Metal 54-18-145

PT 85 Metal 54-18-145; 56-18-150

PT 92 Metal 54-18-145; 57-18-150

Joseph Metal 54-19-140; 56-19-145; 58-19-150

PT 48 Metal 54-19-140; 56-19-145; 60-19-150

7719 Metal 54-19-145; 56-19-145; 60-19-150

L7010 Metal 54-20-140

Gloria Metal 54-20-140; 56-20-145

L7016 Plastic 55-15-140

Exclusive 119 Metal 55-16-140; 57-16-145

Karma Plastic 55-16-140

L7006 Plastic 55-17-140; 57-17-145

UM 72 Plastic 55-18-140; 57-18-145

Eileen Plastic 56-17-140

US 54 Plastic 56-17-140

James Metal 56-17-140; 58-17-145; 60-17-150

L7009 Metal 58-19-150




f) V2025 Frames Listed by Size – Prior Authorization Required

V2025 Frames Listed by Size – Prior Authorization Required


Baby Zero Plastic 31-15

+ Baby Zero Plastic 33-15

Model 6 Metal 33-15-110; 35-16-105; 38-16-110; 41-16-115; 43-18-120

Baby Zero 2 Plastic 34-15

Mini Baby Plastic 34-15

Model 1 Metal 35-16-105; 38-16-110; 40-16-110; 43-18-120

Baby One Plastic 37-14

+ Baby 1 Plastic 37-14

Maxi Baby Plastic 38-12

Baby Lux Plastic 38-17

Model 11 Metal 38-17-105; 40-17-120; 43-17-120

Model 3 Metal 38-16-110; 40-16-110; 43-18-120; 46-18-125

Model 9 Metal 35-16-105; 38-16-110; 40-16-110; 43-16-120; 46-18-125; 48-18-125

+ Baby Lux Plastic 38-17

Beginner Plastic 38-17-120; 40-17-125

Baby Plus Plastic 39-14

Mayan 1 Plastic 39-14

New Baby 1 Plastic 39-17

+ New Baby

1 Plastic 39-17

Maxi Baby 2 Plastic 40-15

Model 2 Metal 40-16-110; 43-16-120; 46-18-125

Baby Lux 2 Plastic 40-18

Model 4 Metal 41-16-115; 43-16-120; 46-18-125

Baby Plus 2 Plastic 42-14


T 28 TR90 42-15-125

Eva Plastic 42-16


+ New Baby 2

Plastic 42-16

Model 7 Metal 42-16-120; 45-16-120; 48-20-125

Model 8 Metal 43-16-120; 46-18-125

Model 16 Metal 43-17-120; 51-20-130




V2025 Frames Listed by Size – Prior Authorization Required


Model 14 Metal 43-18-120; 46-20-125; 48-20-130

Model 13 Metal 43-20-120; 46-20-125; 48-22-130; 51-22-130

Baby One 2 Plastic 44-16

T 18 TR90 44-17-125


+ New Baby 3

Plastic 45-17

Model 12 Metal 46-18-120; 48-18-125

FX1 Titanium 46-19-140

Model 15 Metal 46-20-125; 48-20-130; 54-22-135

Youth TR90 47-15-125



Split A TR90 47-17-140


Nicki 48 Plastic 48-16

T 30 TR90 48-16-125

Model 5 Metal 48-18-125; 51-18-125


Nick 50 Plastic 50-19


Split C TR90 51-16-145



Brian TR90 53-18-140

Nick 53 Plastic 53-19











g) V2020 Frame Descriptions

V2020 Frame Descriptions

Frame

Name

Manufacturer Material Picture Sizes Colors


Spring Hinge, Adjustable Nose Pads

50-18-140 Burgundy Coffee

Ink



47-20-140 Black Coffee

Gunmetal



54-19-145

56-19-145

60-19-150

Black Coffee

Gunmetal

14th Avenue

Limited Editions Plastic

Saddle Bridge

48-16-135

Black

Burgundy Grey

Tortoise

5th Avenue


Saddle Bridge

47-17-140

Mocha Marble

Tortoise Black

Blush


Saddle Bridge

51-16-140 Black

Burgundy

Tortoise


Saddle Bridge

51-16-140 53-16-145

Black Brown

Grey

Adorabl

e Modern Optical Plastic

Saddle Bridge

47-15-135 Black/Blue Black/Brown

Black/Plum





Frame

Name Manufacturer Material Picture Sizes Colors

Agree Modern Optical Plastic

Saddle Bridge

52-16-140

Black/Silver Brown/Gold

Burgundy/Silver


Saddle Bridge

51-16-140

Black/Crystal

Purple/Lilac

Teal/Crystal


Saddle Bridge

48-17-135

50-17-140

Black/Burgund

y Brown

Drk. Blue/Lt. Blue


Saddle Bridge

52-15-140 Black Blue

Brown

Appeal Modern Optical Plastic

Saddle Bridge

51-20-140

Blue/Purple

Grey/Blue Tortoise/Burg

undy



48-20-140 50-20-145

Brown Gold

Gunmetal

Attitude

18 Zimco Optics Plastic

Saddle Bridge

49-17-135

Black

Blue Cranberry



47-19-135 Blue

Brown

Matte Black

Bashful Modern Optical Plastic

Saddle Bridge

42-16-130

Black/Crystal Blue/Rose

Burgundy/Blue





Frame




50-18-135

52-18-140

Antique Silver

Gold

Matte Brown Rose

Bicycle Modern Optical Plastic

Saddle Bridge

45-15-130

47-15-135

Black Matte

Navy Matte Purple Matte


Saddle Hinge, Saddle Bridge

50-15-135 52-15-140

Black

Blue Brown

Bria Modern Optical Metal


53-16-135

Brown

Lilac Rose


Saddle Bridge

54-16-145 Black

Tortoise

Camille Modern Optical Metal

Spring Hinge, Adjustable Nose Pads,

Nylon Rimless

51-19-135

Gunmetal

Light Brown Rose


Saddle Bridge

50-17-130

52-17-135

Black

Brown Plum

Capricor

n Modern Optical Metal


Nylon Rimless

47-20-135

49-20-140

Matte Black Matte Brown

Matte Silver

Care Modern Optical Plastic

Saddle Bridge

42-15-125

44-15-130

46-15-135

Black/Crystal Navy/Crystal

Pink/Crystal Purple/Crystal





Frame


Caribbean

Zimco Optics Metal

Spring Hinge

51-19-140

Brown

Gold Gunmetal


Saddle Bridge

50-17-140

52-17-145

Black

Brown Burgundy


Spring Hinge, Saddle Bridge

48-18-130 50-18-135

Black/Lime

Brown Burgundy

Cheerful Modern Optical Metal


40-18-120

42-18-125 44-18-130

Brown Amber

Black Gold

Pink

Chelsea Zimco Optics Metal


48-18-135 Gold

Gunmetal

Matte Brown

Chill Modern Optical Plastic

Saddle Bridge

51-17-140

Black/Blue Black/Lilac

Black/Lime

Black/Orange Black/Pink

Black/Purple Black/Red

Black/White Black/Turquoi

se


Keyhole Bridge

50-20-140

52-20-145

Blonde

Demi Amber Grey

Climb Modern Optical Plastic

Saddle Bridge

45-16-130

Black/Aqua

Matte Black/Lime

Matte Black/Red

Matte





Frame



Saddle Bridge

53-16-145

Black

Brown Grey


Saddle Bridge

52-18-140 Brown Fade Grey Fade

Compli

ment Modern Optical Plastic

Saddle Bridge

53-16-135

Navy Blue Fade

Purple Fade Wine Fade


Saddle Bridge

53-18-135

Black/Red

Black/White Brown/Caram

el

Confetti Modern Optical Plastic

Saddle Bridge

45-16-125

Blue

Fuchsia Teal


Saddle Bridge

50-17-135

52-17-140

Brown

Grey Rose


Saddle Bridge

48-20-145

50-20-150

50-22-150

52-22-150

52-24-150

54-22-150 54-24-150

Black

Brown Grey

Cutie Modern Optical Metal


32-15-115

35-15-120

Purple

Brown Gold

Cyclone Modern Optical Metal


Nylon Rimless

50-19-140 Brown

Gunmetal

Navy





Frame


Dance Modern Optical Metal

Saddle Bridge

53-16-140

Black/Aqua

Black/Lilac

Tortoise

Dawn Modern Optical Metal


41-16-120

43-16-125 45-16-130

Brown

Pink Purple



49-20-135

51-20-140

53-20-145

Brown Gold

Rose


Saddle Bridge

51-17-135 Black

Tortoise

Diana Modern Optical Metal


52-18-135 Brown Lilac

Rose


Saddle Bridge, Spring Hinge

50-19-140

52-19-145

54-19-150

Black

Brown Grey



52-20-140

54-20-145 56-20-145

Antique Silver

Gold Matte Brown

Downto

wn Limited Editions Plastic

Saddle Bridge

48-18-140

Black Burgundy

Midnight Tortoise

Dynamit

e Modern Optical Metal


42-18-130

45-18-135 47-18-140

Brown

Black Silver





Frame


Eileen Modern Optical Plastic

Saddle Bridge

56-17-140

Black/Crystal

Brown/Crystal Burgundy/Pink


Saddle Bridge

51-18-140 Black/White

Blue

Brown/Beige

EQ301 Eye Q Plastic

Saddle Bridge

52-17-140 Black

Tortoise

EQ313 Eye Q Plastic

Saddle Bridge

52-16-140 Black Purple


Saddle Bridge

50-19-140

Black/Grey

Black/Pink Black/Purple

Black/Red Black Matte

Ethel Modern Optical Metal


49-18-135

52-18-140 55-18-140

Black/Silver Matte Gold

Demi Amber/ Antique

Brown

Exclusive 119

Continental Optical

Metal


55-16-140 57-16-145

Brown Gold

Gunmetal

Exclusiv

e 120

Continental

Optical Metal


53-18-140

55-18-145

Brown Matte Gold

Silver

Exclusiv

e 157

Continental

Optical Metal


Nylon Rimless

51-19-140

Brown

Gunmetal Black





Frame


Falcon Modern Optical Plastic

Saddle Bridge

47-20-140

Black Brown

Crystal Demi Amber


Saddle Bridge

51-19-140 Black Brown

Teal



48-19-135

50-19-140

52-19-145

Brown

Silver Gold



49-17-135

Brown

Matte Black Rose


Saddle Bridge

51-17-140

Brown/Black

Burgundy/Blac

k Purple/Black

Forbidden

Modern Optical Plastic

Saddle Bridge

48-18-140 Black

Tortoise

Wine

Freedom


Saddle Bridge

50-16-140

Black/Blue

Black/Burgundy Black/Frost

Fregossi

368

Continental

Optical Plastic

Saddle Bridge

50-18-135

Black

Aqua Sunset

Gemini Modern Optical Plastic


47-18-135

Blue

Brown Matte Black





Frame



Keyhole Bridge

47-21-140

Tortoise

Burgundy Black



47-17-135 49-17-140

Black/Crystal

Brown/Crystal

Purple/Brown

Glenn Modern Optical Metal


53-18-140 55-18-145

Matte Black

Matte Brown Matte

Gunmetal

Gloria Modern Optical Metal


54-20-140

56-20-145

Brown

Rose Violet

Goodies Modern Optical Plastic

Saddle Bridge

45-16-130

Black/Blue

Black/Fuchsia Black/Lime


Saddle Bridge

51-16-140

Black/White

Brown Burgundy/Blac

k


Saddle Bridge

50-19-140

Blue/Purple Grey/Blue

Tortoise/Burgundy

Heat Modern Optical Metal


Nylon Rimless


Gunmetal


Saddle Bridge


Hide &

Seek Modern Optical Metal


42-19-125

44-19-143

Brown

Navy Purple





Frame



Saddle Bridge

54-17-140

Black

Purple Red

Hudson Zimco Optics Metal


47-20-140

Gold

Brown Gunmetal



51-19-135

53-19-140

Antique Silver Black

Matte Brown Satin Gold

Incognit

o Modern Optical Plastic

Saddle Bridge

47-18-135

Black Matte Blue Matte

Tortoise Matte

J 4154

(Formerl

y Blvd 4154)

Hart Specialties Metal


47-18-135

50-18-140

Brown Gold

Silver

James Modern Optical Metal


56-17-140

58-17-145

60-17-150

Coffee

Gold Gunmetal

Jazz Modern Optical Metal Spring Hinge, Adjustable Nose Pads,

Plastic Temples

52-18-140

54-18-145

56-18-150

58-18-155

60-18-155

Black Brown

Gunmetal

Joseph Modern Optical Metal


54-19-140

56-19-145

58-19-150

Black Matte Brown

Silver





Frame



Saddle Bridge

50-16-135

53-16-140

Black/Crystal

Tortoise Wine/Grey

Karma Modern Optical Plastic



Lavender

Keith Modern Optical Metal


54-16-140

56-16-145

58-16-150

Antique Silver Gold

Matte Brown

Keynote Zimco Optics Metal


51-17-135

Matte Black

Matte Brown Matte Plum



52-18-140 54-18-145

Black

Brown

Gunmetal


Saddle Bridge

52-16-130 54-16-135

Wine Crystal

Black/Crystal Purple/Crystal


Saddle Bridge

52-14-130

Blk/Honey

Crystal

Brown Crystal Dark Plum

Crystal


Saddle Bridge

52-16-130

54-16-135

Purple/Crystal

Black/Crystal Brown/Crystal





Frame



Saddle Bridge

50-16-138

52-16-135

Black/Magenta

Black/Honey Wine Crystal

L6005 Lantis Metal


51-19-130 Shiny Wine Satin Brown

Shiny Black

L6006 Lantis Metal


52-18-135 Satin Brown Satin Plum

Shiny Wine

L6007 Lantis Metal


53-18-138

Shiny Wine

Satin Gold

Satin Brown


Saddle Bridge

51-17-130

Pink/Crystal

Brown/Crystal

Rose/Crystal

L6009 Lantis Metal


48-18-125

Satin Brown

Shiny Wine Satin

Gold/Brown





Frame


L6010 Lantis Metal


49-16-130 Satin Brown Satin Black

Satin Silver

L6011 Lantis Metal


50-18-130

Satin Pink

Satin Brown Satin Plum

L6012 Lantis Metal


49-18-130 Satin Plum Satin Brown

Shiny Wine


Saddle Bridge

53-17-135 Lavender

Black

Tortoise


Saddle Bridge

52-16-135

Black

Brown Purple


Saddle Bridge

52-17-145 Burgundy

Black

Lavender

L7001 Lantis Metal


54-18-138

Matte Black

Satin Brown Satin

Gold/Brown





Frame



Saddle Bridge

53-16-138 55-16-140

Shiny Black

Charcoal/Crystal

Brown/Crystal

L7003 Lantis Metal


52-19-140

Satin Brown

Matte Black Satin

Gunmetal

L7004 Lantis Metal


52-18-135

Satin Gunmetal

Satin Brown Matte Black

L7005 Lantis Metal


50-19-135

Satin

Gunmetal Satin Gold

Satin Brown


Saddle Bridge

55-17-140

57-17-145

Black/Crystal

Brown Crystal Tortoise


Saddle Bridge

53-15-145 55-17-145

Shiny Black

Brown Crystal Tortoise





Frame



Saddle Bridge

53-17-135

Brown Crystal

Black/Crystal Tortoise

L7009 Lantis Metal


58-19-150

Satin Brown Dark

Gunmetal Satin Gold

L7010 Lantis Metal


54-20-140

Matte Black Satin

Gunmetal Satin Gold

L7011 Lantis Metal


54-18-145

Satin Dark

Brown Satin

Gunmetal Matte Black

L7012 Lantis Metal


51-18-135

Satin

Gunmetal Satin Brown

Matte Black


"Cold Insert"

Saddle Bridge

52-18-140 Black Gray

Navy





Frame



Saddle Bridge

55-15-140

Gray

Black Tortoise


Saddle Bridge

52-17-145

Gray

Matte Black Tortoise

L8001 Lantis Metal


44-18-125

Satin Brown Satin

Gunmetal Satin Navy


Saddle Bridge

46-15-125

Black/Crystal

Brown/Crystal Purple/Pink

Crystal

L8003 Lantis Metal


48-17-135

Matte Black/Navy

Satin Brown

Satin Gun/Black

L8004 Lantis Metal


47-17-130

Satin Pink

Satin Brown Satin

Gun/Black

L8005 Lantis Metal


36-17-140

38-17-140 40-18-140

Satin Light

Brown





Frame



Saddle Bridge

45-15-128

Navy/Crystal

Brown/Crystal Black/Crystal


Saddle Bridge

47-16-130

49-16-130

Black/Crystal Brown/Crystal

Red/Crystal

L8008 Lantis Metal


44-19-130

Satin

Gunmetal Satin Slate

Blue Satin Brown

L8009 Lantis Metal


46-18-130

Satin Light

Plum

Satin Gun/Black

Satin Brown

L8010 Lantis Metal


45-19-125 Satin Pink Satin Red

Satin Brown

L8011 Lantis Metal


42-18-120

Slate Blue Satin Brown

Satin Light Plum

L8012 Lantis Metal


46-18-125 Satin Brown Satin Pink

Slate Blue





Frame



Saddle Bridge

47-16-130

Brown/Crystal

Black/Crystal Blue/Crystal


Saddle Bridge

48-16-130

50-16-130

Blk/Magenta

Crystal Purple/Pink

Crystal Blk/Green

Crystal


Saddle Bridge

45-17-126 Teal/Crystal

Purple/Crystal

Pink/Crystal


Saddle Bridge

45-16-127

Black/Green Crystal

Brown/Crystal Red/Crystal


Saddle Bridge

46-17-130

Purple Crystal

Black Magenta

Crystal


Saddle Bridge

42-16-128 45-16-130

Teal Blue

Crystal Pink Crystal

Black


Saddle Bridge

45-13-128

Purple Crystal

Navy Crystal

Brown Crystal





Frame



Saddle Bridge

46-16-135

48-14-128

Black Brown Crystal

Navy Crystal

L8021 Lantis Metal


50-17-130

Satin Gun/Navy

Matte Black

Satin Brown

L8022 Lantis Metal


47-15-130

Satin Navy

Satin Gun/Black

Satin Brown

L8023 Lantis Metal


48-16-135

Satin Magenta

Satin Purple Satin Brown

L8024 Lantis Metal


48-16-130

Satin

Blk/Purple Satin Brown

Satin Plum


Saddle Bridge

48-15-130

Black

Navy Tortoise


Saddle Bridge

46-15-130 Rose Black

Red





Frame



Saddle Bridge

48-17-130

Red

Black Teal


Saddle Bridge

46-17-130 Black Navy

Tortoise


Saddle Bridge

44-16-125

Navy

Black Tortoise


Saddle Bridge

51-18-140 Black/Grey Black/Red

Black/White


Saddle Bridge

48-20-145

50-20-150

50-22-150

52-20-140

52-22-150

52-24-150

54-20-150

54-22-150

54-24-150

56-22-150

56-24-150

Black

Brown



49-18-130 51-18-135

Coffee

Gold Demi Amber

Lisa Modern Optical Metal


52-17-135

55-17-140

Brown

Rose Violet





Frame


Liz Zimco Optics Metal


53-16-140

Brown

Demi Amber Matte Gold

Lollipop Cable

Modern Optical Metal


39-20-130

41-20-135

43-20-140

Amber Brown

Rose

Lollipop Skull



39-20-120

41-20-125

43-20-125

Amber

Brown Rose



43-20-130

46-20-135

49-20-140

52-20-145

Brown

Demi Amber Pink


Saddle Bridge

50-16-135 Black/Rose Black/Violet

Brown

Mainstre

et 415 Hart Specialties Plastic

Saddle Bridge, Cable Temples

33-20-115

36-20-120

39-20-125

Blue Brown

Pink

Manhattan


Saddle Bridge

50-17-140 Blue Crystal

Brown Crystal

Rose Crystal


Saddle Bridge

54-16-140

Black/Blue

Black/Brown Black/Burgund

y

Metropolitan


Saddle Bridge

53-18-150

Black Matte

Crystal Tortoise





Frame



Saddle Bridge

53-18-135

Black

Brown Burgundy

Monaco Modern Optical Metal


48-18-140

Brown

Gold Gunmetal

Monica Modern Optical Plastic

Saddle Bridge

50-17-130

52-17-135

54-17-140

Brown Grey

Rose

Moscow Zimco Optics Metal


54-16-140

56-18-145 58-18-150

Gold

Gunmetal Amber

Nancy Modern Optical Metal


52-18-135

Antique

Brown

Gold Silver

Neon Modern Optical Plastic

Saddle Bridge

45-19-140 Blue

Brown

Burgundy

Ninja Modern Optical Metal


44-18-130 46-18-135

Black Blue

Brown Burgundy

Violet


Saddle Bridge

53-15-140 Black/Rose Blue/Pink

Brown

Overloo

k Zimco Optics Metal



Gunmetal





Frame


Overvie

w Modern Optical Plastic

Saddle Bridge

50-22-145

Amethyst

Black Brown

Grey Purple

Pacific Zimco Optics Metal


53-18-135

Brown

Matte Gunmetal

Shiny Gold


Saddle Bridge

53-20-145

Blue Fade

Burgundy Fade

Grey Fade

Patches Modern Optical Plastic

Saddle Bridge

45-18-130

Black/Crystal

Navy/Crystal Purple/Crystal


Saddle Bridge

54-14-140

Blue Matte

Plum Matte Black/Tortoise

Matte

Phase Modern Optical Plastic

Saddle Bridge

52-17-145 Blue

Burgundy

Teal

Pixie Modern Optical Plastic

Saddle Bridge

48-16-130 Brown/Crystal Black/Crystal

Plum/Crystal


Saddle Bridge

51-16-140 53-16-145

Black Brown

Navy


Saddle Bridge

52-18-140

Black

Teal/Crystal Tortoise





Frame



Saddle Bridge

51-18-140

Black/Crystal

Grey

Red



54-19-140

56-19-145 60-19-150

Black Gold Gold

Gunmetal


Spring Hinge, Unifit Bridge

53-16-140

55-16-145

Coffee Gold

Gunmetal



44-16-125

Burgundy

Coffee

Denim



51-18-135

53-18-140

Pewter Brown

Plum



42-17-125

45-17-130

48-19-135

Brown

Black Blue



54-18-145

56-18-150

Black Brown

Gunmetal



50-18-135 Brown

Burgundy

Purple





Frame




49-18-135

Black

Brown Gunmetal



54-18-145 57-18-150

Black

Gunmetal

Brown

Pumpkin

(Cable) Modern Optical Metal


Cable Temples

40-16-130

42-16-135

Black Blue

Gold Brown

Pumpkin

(Skull) Modern Optical Metal


40-16-120

42-16-125

Black Blue

Brown Gold


Keyhole Bridge

52-17-140

54-17-145

56-17-150

Black Brown

Grey

Randi Modern Optical Metal


44-16-125

46-16-130

Purple

Brown Pink

Relax Modern Optical Plastic

Saddle Bridge

50-19-140 Black/Tortoise Plum/Tortoise

Teal/Tortoise


Saddle Bridge


Brown


Saddle Bridge

50-17-135

Black

Brown Burgundy





Frame



Saddle Bridge

52-16-140

Brown

Blue

Pink


Saddle Bridge

52-16-140 Blue

Pink/Grape

Violet


Saddle Bridge

49-19-135 Brown

Grey


Saddle Bridge

48-20-140 Black/Crystal

Brown/Crystal

Sadie Modern Optical Plastic Spring Hinge, Saddle Bridge, Laser

Engraved Floral Design, Multi-faceted

Gemstones


Burgundy

Score Modern Optical Plastic

Saddle Bridge

44-15-130

46-15-135

Black

Tortoise


Saddle Bridge

51-15-140 Black/Blue Black/Mint

Black/Violet

Skippy Modern Optical Plastic

Saddle Bridge

44-16-125 46-16-130

Blue Brown Rose


Saddle Bridge

47-17-130

49-17-135

Black

Brown Burgundy





Frame




49-17-135

51-17-140

54-17-145

57-17-150

60-17-150

Black Tortoise

White Red

Slide Modern Optical Metal


48-20-135


Matte Burgundy

Sneaker

s Modern Optical Plastic

Saddle Bridge

42-18-125

45-18-130 47-18-135

Blonde

Brown Blue Wine Grey



46-20-130

48-20-135

50-20-140

Black Brown

Violet

Speckle Modern Optical Plastic


44-17-130

46-17-135

Blue Brown

Purple

Splash Modern Optical Plastic

Saddle Bridge

46-18-130

48-18-135

Black

Blue

Brown Red

Sporty Modern Optical Plastic


44-17-125

46-17-130

Black Blue

Brown

Spunky Modern Optical Plastic

Saddle Bridge

47-16-130

Black/Navy

Black/Pink Black/Red

Black/Sky Blue


Saddle Bridge

48-16-140

Black Blonde

Blue Brown

Burgundy Demi Amber





Frame


Structur

e Modern Optical Plastic

Saddle Bridge

50-17-130

52-17-135

Black Brown

Navy

Studio Modern Optical Metal


51-19-140

Black

Brown Gunmetal

SW319 EyeQ Plastic

Saddle Bridge

48-17-140

Black Crystal

Plum Tortoise

SW444 EyeQ Plastic

Saddle Bridge

51-17-135 Blue

Red

SW445 EyeQ Plastic

Saddle Bridge

52-15-140 Purple

Tortoise



50-19-140

52-19-145

Antique Brown

Black Gold


Saddle Bridge


Burgundy

Tackle Modern Optical Plastic

Saddle Bridge

45-16-130

47-16-135

Black

Navy Tortoise



53-18-140


Matte Gunmetal





Frame


Takeoff Modern Optical Plastic

Saddle Bridge

47-17-135

49-17-140

Black/Blue Black/Grey

Black/Hot Pink

Ted (CC

Temples)



52-19-165CC

54-19-170CC

Black Brown

Gunmetal

Tender Modern Optical Plastic

Saddle Bridge

47-19-130 Black/Teal

Purple

Teal/Black


Saddle Bridge

50-21-140 Brown Black


Saddle Bridge

52-18-140 Black

Brown

Tie-Dye Modern Optical Plastic


45-17-130 47-17-135

Blue

Brown Purple


Saddle Bridge


Burgundy



46-18-135

48-18-140 50-18-145

Antique Brown

Antique Gold Matte Black

Tomorrow



51-17-135

53-17-140

55-17-145

Black Brown

Grey

Tori Modern Optical Plastic


44-15-130

46-15-135

Black

Blue

Brown Pink





Frame



Saddle Bridge

52-18-140

54-18-145

56-18-150

Brown Grey

Smoke


Saddle Bridge


Grey


Saddle Bridge

50-18-145

Black

Brown

Brown Blue


Saddle Bridge

48-20-140 Black Crystal

Brown

Grey Marble


Saddle Bridge

50-19-140

Black

Brown Grey


Not recommended for powers over

+3.00

Saddle Bridge


Mauve


Saddle Bridge

52-18-140

Black

Brown Grey


Saddle Bridge


Grey





Frame



Saddle Bridge

48-18-140

Brown

Tortoise Black Crystal


Saddle Bridge

49-18-135

52-18-140

Black

Burgundy Tortoise


Saddle Bridge

48-18-140

Black

Brown Tortoise


Saddle Bridge

49-15-140 Purple Brown

Black Wine


Saddle Bridge

51-18-135 Brown Blue

Pink


Saddle Bridge

52-20-140 Brown

Pink


Saddle Bridge

52-22-140

54-22-145

Black

Brown Grey


Saddle Bridge

55-18-140

57-18-145

Brown

Grey





Frame



Saddle Bridge

54-18-140 56-18-145

Black

Brown

Grey


Saddle Bridge

51-17-140 Black

Crystal/Black

Tortoise


Saddle Bridge

51-18-145

Charcoal

Ebony Mocha

Tortoise


Saddle Bridge

51-17-140

Black Crystal

Navy/Tortoise Tortoise


Saddle Bridge

51-19-140

Brown Crystal

Wine Black Crystal


Saddle Bridge

56-17-140

Brown

Black Wine



46-15-130

Brown

Pink Purple


Saddle Bridge

51-18-135 Brown Grey

Tortoise


Saddle Bridge

51-17-135

Black

Brown Tortoise





Frame



Saddle Bridge

53-18-145 55-18-150

Black

Brown

Tortoise


Saddle Bridge

51-17-135 53-17-140

Black

Brown Purple

Wine


Saddle Bridge

51-17-140 54-17-145

Black

Grey Tortoise


Saddle Bridge

44-17-130

47-17-135

Black Brown

Blue Red


Saddle Bridge

51-17-140

54-17-145

Black

Brown Tortoise

Vern Modern Optical


52-20-135

54-20-140

Black

Brown Gold


Saddle Bridge

54-17-140

Black/Crystal

Brown/Crystal Navy/Crystal

Whimsy Modern Optical Metal


43-17-120 45-17-125

Black

Brown Violet

Wiggle Modern Optical Plastic

Saddle Bridge

40-16-120

42-16-125

44-16-130

Black Brown

Purple





Frame


Windy Modern Optical Plastic

Saddle Bridge

41-17-120

43-17-125

Black Brown

Violet


Saddle Bridge

49-16-135 51-16-140

Black/Lime

Brown Burgundy/Gre

y


Saddle Bridge

49-18-135

Black/Grey

Black/Hot Pink

Black/Red




h) V2025 Frame Descriptions


Prior Authorization Required

Frame

Name


Baby Lux

Miraflex Plastic

Soft frames made of flexible material with

no metal components or hinges, saddle

bridge, includes headband, Hypoallergenic

38-17 33 colors (see chart at end)

Baby

Lux 2 Miraflex Plastic

Soft frames made of flexible material with no metal components or hinges, saddle


40-18 28 colors (see

chart at end)

Baby

One Miraflex Plastic


no metal components or hinges, saddle bridge, includes headband, Hypoallergenic


chart at end)

Baby One 2

Miraflex Plastic




Baby

Plus Miraflex Plastic




chart at end)






Frame


Baby Plus 2

Miraflex Plastic




Baby

Zero Miraflex Plastic




chart at end)

Baby Zero 2

Miraflex Plastic




Beginne

r Modern Optical TR90

Saddle Bridge

38-17-120

40-17-125

Pastel Blue

Pastel Brown Pastel Rose


Saddle Bridge


Brown






Frame


Eva Miraflex Plastic





chart at end)

FX3 Capri Optics Metal Titanium Memory Metal, Spring Hinge,

Adjustable Nose Pads, Hypoallergenic

50-20-145

Coffee

Gold

Gunmetal

FX4 Capri Optics Metal

Titanium Memory Metal, Spring Hinge, Adjustable Nose Pads, Hypoallergenic


Silver


Titanium Memory Metal, Spring Hinge,


53-20-145

Black

Coffee Gunmetal



53-19-145 Coffee Gold

Silver



55-17-145

Black

Coffee Gunmetal






Frame





52-17-140

Black Coffee

Gunmetal





Gunmetal




53-19-145

Gold

Coffee Gunmetal




52-18-145

Black

Coffee

Gunmetal




Gunmetal



54-18-140

Gold Coffee

Gunmetal



47-19-125 Coffee

Gunmetal

Ink






Frame


Maxi Baby

Miraflex Plastic





Maxi Baby 2

Miraflex Plastic




Mayan 1 Miraflex Plastic Soft frames made of flexible material with



Mayan 2 Miraflex Plastic Soft frames made of flexible material with no metal components or hinges, saddle



chart at end)

Mayan 3 Miraflex Plastic Soft frames made of flexible material with



chart at end)






Frame


Mini Baby

Miraflex Plastic Soft frames made of flexible material with



Model 1 Specs4Us

(Erin's World) Metal

Memory Flexible, Titanium 180◦ Spring

Hinge, Hypoallergenic, Soft Plastic Nose

Pads, Memory Flex Bridge, Wider End

Pieces for Proper Fit

35-16-105

38-16-110

40-16-110 43-18-120

Brown Lilac

Navy Pink

Model 2 Specs4Us


Memory Flexible, Titanium 180◦ Spring Hinge, Hypoallergenic, Soft Plastic Nose



40-16-110

43-16-120 46-18-125

Lilac

Pink Wine

Model 3 Specs4Us




Pads, Memory Flex Bridge, Wider End Pieces for Proper Fit

38-16-110

40-16-110

43-18-120

46-18-125

Sizes 38, 40, 43, 46

Blue Demi

Light Green

Lilac

Sizes 43, 46 Light Blue

Model 4 Specs4Us



Hinge, Hypoallergenic, Soft Plastic Nose Pads, Memory Flex Bridge, Wider End


41-16-115

43-16-120 46-18-125

Green Dark Gunmetal Lt.

Pink

Pink Demi

Navy

Model 5 Specs4Us





48-18-125

51-18-125

Black Demi Brown/Silver

Green Dark Gunmetal Lt.






Frame


Model 6 Specs4Us





33-15-110

35-16-105

38-16-110

41-16-115

Sizes 33 Brown

Pink

Sizes 35, 38,

41 Blue Demi Brown

Gunmetal Pink

Model 7 Specs4Us





42-16-120

45-16-120

48-20-125 43-18-120

Brown

Navy Red

Violet Dark

Model 8 Specs4Us





43-16-120 46-18-125

Brown

Brown/Silver Gold Demi

Navy Orange/Silver

Model 9 Specs4Us





35-16-105

38-16-110

40-16-110

43-16-120

46-18-125 48-18-125

Sizes

35, 38, 40,

43

Dark Green

Dark

Gunmetal

Pink Demi

Wine

Sizes 38, 43 Navy

Sizes 46, 48

Aqua Blue

Brown/Silver Antique Pink






Frame


Model 11

Specs4Us (Erin's World)

Metal




38-17-105

40-17-120

43-17-120

Sizes 38, 40,

43 Black Shiny

Brown

Blue Bright

Wine

Sizes 40, 43

Dark Violet

Model 12


Metal




46-18-120

48-18-125

Dark Violet

Brown Gunmetal

Wine

Model 13


Metal Memory Flexible, Titanium 180◦ Spring



43-20-120

46-20-125

48-22-130

51-22-130

Sizes

43, 46, 48, 51

Brown

Dark Green

Wine

Sizes 46, 48,

51 Shiny Black

Model

14

Specs4Us




43-18-120

46-20-125

48-20-130

Brown/Silver Navy

Lilac

Model 15


Metal Memory Flexible, Titanium 180◦ Spring



46-20-125

48-20-130

54-22-135

Sizes 46, 48 Navy/Blue

Red/Pink

Sizes 46, 48,

54

Brown/Orange

Black/Grey






Frame


Model 16


Metal





43-17-120 51-20-130

Matte Black

Matte Brown

Turquoise

New Baby 1





New

Baby 2 Miraflex Plastic




chart at end)

New






chart at end)

New





chart at end)






Frame


Nicki 48 Miraflex Plastic Soft frames made of flexible material with




Nicki 50 Miraflex Plastic Soft frames made of flexible material with no metal components or hinges, saddle



chart at end)

Nicki 53 Miraflex Plastic Soft frames made of flexible material with


53-19 9 colors (see

chart at end)

Split A Capri Optics TR90

Saddle Bridge

47-17-140 Burgundy

Purple

Blue/Black


Saddle Bridge

51-16-145

Black

Tortoise

Grey/Blue

T 18 Capri Optics Metal


44-17-125

Brown

Black Pink

Purple


Saddle Bridge


Blue






Frame


T 30 Capri Optics TR 90

Saddle Bridge

48-16-125

Black

Brown

Grey

Youth Capri Optics TR 90

Saddle Bridge


Blue




i) New V2025 Frames

New V2025 Frames Prior Authorization Required

Frame

Name


+Baby 1 Miraflex Plastic

Soft frames made of flexible material with no metal components or hinges, built up

saddle bridge, includes headband, Hypoallergenic

37-14

Pink

Dark Blue Dark Grey

Lavender

+Baby Lux


no metal components or hinges, built up saddle bridge, includes headband,

Hypoallergenic

38-17

Pink Magenta

Dark Blue Red

Dark Grey Lavender

+Baby

Zero Miraflex Plastic



Hypoallergenic

33-15

Pink Clear Pink Pearl

Dark Blue

Clear Blue Dark Grey

Lavender

+ New




Hypoallergenic

39-17

Pink

Magenta Dark Blue

Red

Dark Grey Lavender

+ New Baby 2

Miraflex Plastic Soft frames made of flexible material with no metal components or hinges, built up

saddle bridge, includes headband, Hypoallergenic

42-16

Pink Magenta

Dark Blue Red

Dark Grey Lavender




New V2025 Frames Prior Authorization Required

Frame Name


+ New




Hypoallergenic

45-17

Pink

Magenta Dark Blue

Red Dark Grey

Lavender




j) Frame Size and Color Chart



Appendix C. Eye and Vision Services, Provider Handbook Modifications

This table lists the last three years of changes to this handbook as of the publication date.

Eye and Vision Services, Provider Handbook Modifications

Version Section/

Column

Modification Description Date SME

23.0 All Published version 12/29/2020 TQD

22.12 2.1. Ophthalmologists

Updated to include enrollment

requirements previously listed in separate

document.

12/16/2020 W Deseron

E Garibovic

22.11 2.3. Optometrists Updated to include enrollment

requirements previously listed in separate

document.


E Garibovic

22.10 Appendix A, a)

References:

Preapproved

Diagnoses for

Chronic and Acute

Conditions

New subsection. 12/16/2020 W Deseron

E Garibovic

22.9 10.1. Prior

Authorization

Requests: Medical

Care Unit

Updated DXC to Gainwell in section.

Updated process for checking status of PA.


E Garibovic

22.8 8.5.2. References:

Vision Therapy

Renamed References: Visual Processing

Therapy. Added references.


E Garibovic

22.7 8.4.5. Vision

Therapy: Prior

Authorization (PA)

Requests

Updated DXC to Gainwell in section.

Updated process for checking status of PA.


E Garibovic

22.6 6. Covered

Services and

Limitations:

Pharmaceuticals

Updated DXC to Gainwell in section. 12/16/2020 W Deseron

E Garibovic

22.5 3. Eligible

Participants


E Garibovic

22.4 2.2 Opticians Clarified opticians can be enrolled. 12/16/2020 W Deseron

E Garibovic

22.3 1.3 Medicaid Updated process for checking status of PA. 12/16/2020 W Deseron

E Garibovic

22.2 1.2 Provider

Relations

Consultants


E Garibovic

22.1 1.1 DXC

Technology

Renamed Gainwell Technology. 12/16/2020 W Deseron

E Garibovic


21.76 Appendix C. Eye

and Vision

Services, Provider

Handbook

Modifications

Added information about table retention. 10/28/2020 W Deseron

E Garibovic

21.75 Appendix B.

Frame Brochure

for Idaho Medicaid

Vision

Updated available frames. 10/28/2020 W Deseron

E Garibovic

21.74 Appendix A.

Preapproved

Diagnoses for

Chronic and Acute

Conditions

Added diagnoses. 10/28/2020 W Deseron

E Garibovic

21.73 1.7 References Deleted. Moved to individual sections. 10/28/2020 W Deseron

E Garibovic



Version Section/

Column


21.72 1.6.3 References:

Reimbursement

Deleted. Moved to individual sections. 10/28/2020 W Deseron

E Garibovic

21.71 11.3. Third Party

Insurance Billing

Added where to go for more information. 10/28/2020 W Deseron

E Garibovic

21.70 11.2. Medicare

Crossovers for

Vision Services

Added where to go for more information. 10/28/2020 W Deseron

E Garibovic

21.69 11.1. References:

Reimbursement

New section. 10/28/2020 W Deseron

E Garibovic

21.68 11.

Reimbursement

Updated requirements and information. 10/28/2020 W Deseron

E Garibovic

21.67 10.2. Prior

Authorization (PA)

Requests: NVA

Renamed Prior Authorization Requests:

NVA.


E Garibovic

21.66 10.1. Prior

Authorization (PA)

Requests: Medical

Care Unit

Renamed Prior Authorization Requests:

Medical Care Unit. Added information

about checking notes.


E Garibovic

21.65 10. Prior

Authorization (PA)

Requests

Renamed Prior Authorization Requests.

Added some clarifying instructions.


E Garibovic

21.64 8.5. Visual

Processing

Therapy


E Garibovic


Vision Therapy

Added references. 10/28/2020 W Deseron

E Garibovic

21.62 8.3. Interactive

Metronome

Therapy


E Garibovic

21.61 8.2. Eye Exercise

Therapy


E Garibovic


Covered Services

and Limitations –

Therapy Services


E Garibovic

21.59 8.Covered

Services and

Limitations:

Therapy Services


E Garibovic

21.58 7.5.

Photorefractive

Keratectomy


E Garibovic

21.57 7.4. Lasik New section. 10/28/2020 W Deseron

E Garibovic

21.56 7.3. Corneal

Transplants

New section. Points provider to Hospital

handbook.


E Garibovic


Blepharoplasty


E Garibovic

21.54 7.2.

Blepharoplasty

New section. Incorporates newsletter

article about coverage.


E Garibovic


Optometrists

Performing

Procedures


E Garibovic

21.52 7.1. Optometrists

Performing

Procedures

New section. Incorporates newsletter

article about optometrists billing for

procedures.


E Garibovic

21.51 7. Covered

Services and

Limitations:

Surgery and

Procedures

New section. Provides information on eye

surgeries following Physician and Non-

Physician Practitioner handbook.


E Garibovic



Version Section/

Column



Covered Services

and Limitations:

Pharmaceuticals


E Garibovic

21.49 6. Covered

Services and

Limitations:

Pharmaceuticals

New section. Establishes optometrist’s

ability to be reimbursed for administering

pharmaceuticals.


E Garibovic


Tonometry


E Garibovic


Covered Services

and Limitations:

Examinations and

Diagnostics


E Garibovic

21.46 5. Covered

Services and

Limitations:

Examinations and

Diagnostics

New section. Moved visual examinations

here.


E Garibovic


Non-Covered

Services


E Garibovic

21.44 4.8. Non-Covered

Services

Clarified section and process. 10/28/2020 W Deseron

E Garibovic


Fitting

Fee/Dispensing

Fee


E Garibovic

21.42 4.7. Fitting

Fee/Dispensing

Fee

Added CPT 92071. 10/28/2020 W Deseron

E Garibovic

21.41 References:

Frames and

Lenses

Deleted. 10/28/2020 W Deseron

E Garibovic

21.40 4.6. Miscellaneous

Supply

Minor, non-substantial wording. 10/28/2020 W Deseron

E Garibovic

21.39 4.5. Eye Glasses

for Cataract

Surgery


E Garibovic

21.38 a) References:

Tinted Lenses


E Garibovic

21.37 4.4.7. Tinted

Lenses

New section. Content incorporated from

previous Frames and Lenses section and

expounded upon to incorporate newsletter

articles.


E Garibovic


Progressive

Lenses


E Garibovic

21.35 4.4.6. Progressive

Lenses


previous Frames and Lenses section.


E Garibovic


Photochromatic/Tr

ansition Lenses


E Garibovic

21.33 4.4.5.

Photochromatic/Tr

ansition Lenses




E Garibovic

21.32 4.4.4. Lenticular

Lens Material




E Garibovic

21.31 4.4.3. High Index

Lens Material




E Garibovic

21.30 4.4.2. Aspheric

Lenses




E Garibovic



Version Section/

Column



Eyeglass Lenses


E Garibovic

21.28 4.4. Eyeglass

Lenses

New section about eyeglass lens coverage. 10/28/2020 W Deseron

E Garibovic

21.27 4.3.2. Deluxe

(Specialty)

Frames

Moved under Eyeglass Frames section. 10/28/2020 W Deseron

E Garibovic


Eyeglass Frames


E Garibovic

21.25 4.3. Eyeglass

Frames

New section about eyeglass frame

coverage.


E Garibovic

21.24 1.3.2 Frames and

Lenses.

Deleted. Divided into Eyeglass Frames and

Eyeglass Lenses sections.


E Garibovic


Contact Lenses for

Keratoconus


E Garibovic

21.22 4.2.3. Contact

Lenses for

Keratoconus

Minor, non-substantial wording and link to

PA section.


E Garibovic


Contact Lenses


E Garibovic

21.20 4.2. Contact

Lenses

Minor, non-substantial wording and link to

PA section.


E Garibovic

21.19 4. Covered

Services and

Limitations


E Garibovic


Eligible

Participants

Deleted. 10/28/2020 W Deseron

E Garibovic

21.17 3.3. EPSDT

Services for

Participants Under

21

Added information about where billing

requirements are found.


E Garibovic


Age Restrictions


E Garibovic

21.15 3.2. Age

Restrictions


E Garibovic

21.14 3.1. Referrals Minor, non-substantial wording. 10/28/2020 W Deseron

E Garibovic

21.13 3. Eligible

Participants


E Garibovic


Optometrists


E Garibovic

21.11 2.3. Optometrists New section. Provides information for

Optometrists to be eligible to enroll in

Medicaid.


E Garibovic


Opticians


E Garibovic

21.9 2.2. Opticians New section. Provides information for

opticians providing services.


E Garibovic


Ophthalmologists


E Garibovic

21.7 2.1.

Ophthalmologists

New section. Provides information for

Ophthalmologists to be eligible to enroll in

Medicaid.


E Garibovic

21.6 1.4. National

Vision

Administrators

New section. Provides contact information. 10/28/2020 W Deseron

E Garibovic

21.5 1.3. Medicaid New section. Provides contact information. 10/28/2020 W Deseron

E Garibovic

21.4 1.2. Provider

Relations

Consultants


E Garibovic



Version Section/

Column


21.3 1.1. DXC

Technology


E Garibovic

21.2 1. Important

Contacts

Added how to use handbook and

description of references.


E Garibovic

21.1 Eye and Vision

Services

Added how to use handbook and

description of references.


E Garibovic


19.8 Appendix A.

Preapproved

Diagnoses for

Chronic and Acute

Conditions

Modified section name. Added language to

specify the diagnosis codes must specify

which eye the diagnosis applies to.

11/26/19 W Deseron

E Garibovic


Reimbursement

New subsection 11/26/19 W Deseron

E Garibovic

19.6 1.6

Reimbursement

Added reminder of applicability of co-pays. 11/26/19 W Deseron

E Garibovic

19.5 1.4

Documentation

Requirements

New section 11/26/19 W Deseron

E Garibovic

19.4 1.3.9.3 Vision

Therapy:

Coverage and

Limitations

Clarified that treatment must be one-on-

one.

11/26/19 W Deseron

E Garibovic

19.3 1.3.9.1 Vision

Therapy: Provider

Qualifications

Removed optometric vision therapist as a

valid provider type

11/26/19 W Deseron

E Garibovic

19.2 1.3.2.5

References:

Frames and

Lenses

New subsection 11/26/19 W Deseron

E Garibovic

19.1 1.2 Eligible

Participants

Removed reference to the Pregnant

Women program.

11/26/19 W Deseron

E Garibovic


18.3 Appendix C Renamed from Section Modifications.

Removed changes dating back prior to

three years.

8/21/19 K Duke

W Deseron

18.2 1.3.9 Vision

Therapy

Added reference to American Optometric

Association. Format changes.

8/21/19 K Duke

W Deseron

18.1 1.3.8.3 Evaluation

and Management

Added E&M requirements from Physician

and Non-Physician Practitioner Handbook

8/21/19 K Duke

W Deseron


17.6 1.4. Prior

Authorization (PA)

Requests

Section added to provide more information

about requesting authorizations.

6/13/19 W Deseron

E Garibovic

17.5 1.3.9. Vision

Therapy

Section updated to match current policy. 6/13/19 W Deseron

E Garibovic

17.4 1.3.1.2. Contact

Lenses for

Keratoconus

Updated to match previously posted policy. 6/13/19 W Deseron

E Garibovic

17.3 1.3. Covered

Services and

Limitations

Updated throughout with information

about prior authorizations.

6/13/19 W Deseron

E Garibovic

17.2 1.2. Eligible

Participants

Added information about requirements for

checking eligibility. Also added EPSDT

eligibility.

6/13/19 W Deseron

E Garibovic

17.1 1. Eye and Vision

Services

Updated title. Added reference to

requirement to follow general handbooks.

6/13/19 W Deseron

E Garibovic


16.1 All Changed all language, contact information

to reflect new contractor, revised frame

brochure for CCF 10843B1

9/14/18 C Cockrum

D Baker

E Garibovic




Version Section/

Column


15.6 2.6.6-2.6.9 New

Patient Exam &

Established

Patient Exam

Moved under vision exams 7/2/18 W Deseron

D Baker

E Garibovic

15.5 2.4.1. Medicare

Crossovers for

Vision Services

Removed redundancy 7/2/18 W Deseron

D Baker

E Garibovic

15.4 2.3.1.2 Frames

and Lenses

Clarified language about Medicare's

contractor

7/2/18 W Deseron

D Baker

E Garibovic

15.3 2.3.1.2.1. Lenses Changed photochromatic to non-covered 7/2/18 W Deseron

D Baker

E Garibovic

15.2 2.3.1.3. Fitting

Fee/Dispensing

Fee

Cleaned up language 7/2/18 W Deseron

D Baker

E Garibovic

15.1 All Clarifications, format changes, inclusion of

posted policies.

7/2/18 W Deseron

D Baker

E Garibovic


14.1 2.6.2.3 Fundus

Photography

New section 3/8/18 W Deseron

D Baker

E Garibovic


13.1 2.6.6 Prior

Authorization

Updated for TPA upgrade 1/6/18 T Humpherys

D Baker

E Garibovic