HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
Vision Care Coverage of Eyeglasses Adults 21 years of Covered Coverage of Eyeglasses Adults 21 years of age and over: age and over: A $100 allowance toward eyeglasses every Limited to one pair of eyeglasses (frames and two calendar years. Limited to one pair of eyeglasses (frames and lenses) every two rolling years (24 month lenses) every two rolling years (24 month No exceptions will be made to replace period measured backward from the date of period measured backward from the date of broken, lost or stolen eyeglasses until the two service) unless a new pair is medically service) unless a new pair is medically year limitation is met. necessary due to a change in the client’s necessary due to a change in the client’s medical condition (e.g. cataract surgery; HUSKY Health members covered under medical condition (e.g. cataract surgery; tumors; stroke; diabetes or a change in visual HUSKY B have $15.00 copays. tumors; stroke; diabetes or a change in visual acuity by at least 1 diopter since the last acuity by at least 1 diopter since the last Professional services of an optometrist or prescribed pair.) prescribed pair.) ophthalmologist are not subject to the one Note: if a member elects to ONLY upgrade service every two year limitation. Note: if a member elects to ONLY upgrade their lenses and not their frames at the time their lenses and not their frames at the time $15 co-pay for eye exams. or vice versa on the same date of service for or vice versa on the same date of service for which they were allowed to receive a new Deluxe Frames which they were allowed to receive a new pair of glasses, this will be treated as having pair of glasses, this will be treated as having Deluxe Frames: Please refer to policy exhausted the full benefit, and the member exhausted the full benefit, and the member transmittal PB 2015-102 New Coverage will NOT be eligible for a new set of frames or will NOT be eligible for a new set of frames or Guidelines for Code V2025 Deluxe Frames. lenses until the following rolling two year lenses until the following rolling two year Deluxe frames are considered medically period has been exhausted and/or is over. period has been exhausted and/or is over. necessary for clinical circumstances for Vision providers must verify that no other children ages 0 to 5 and those members who Vision providers must verify that no other provider has submitted a claim for a pair of are 6 years of age and older must include one provider has submitted a claim for a pair of eyeglasses in the previous 2 rolling years by or more correlating diagnosis codes. eyeglasses in the previous 2 rolling years by reviewing claim history. reviewing claim history. Members under 21 years of age that have No prior authorization is needed for broken lenses that are in a deluxe frame and No prior authorization is needed for eyeglasses that are medically necessary due have no change in vision the member shall eyeglasses that are medically necessary due to a change in medical condition. receive a new pair of lenses that can be to a change in medical condition. accommodated in the existing deluxe frame The above limit of one pair of eyeglasses The above limit of one pair of eyeglasses unless the deluxe frame has been every two years applies regardless of medical every two years applies regardless of medical compromised. necessity for a second pair of glasses or two necessity for a second pair of glasses or two pairs in lieu of bifocals. Deluxe frames will be replaced only if pairs in lieu of bifocals.
1 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312 HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
No exceptions will be made to replace medically necessary due to a change in the No exceptions will be made to replace broken, lost or stolen eyeglasses until the two member’s medical condition which results in broken, lost or stolen eyeglasses until the two year limitation is met. the need to provide a new lens that cannot year limitation is met. be accommodated in the existing frame. Professional services of an optometrist or Professional services of an optometrist or Eyeglasses with deluxe frames that are lost or ophthalmologist are not subject to the one ophthalmologist are not subject to the one stolen will be replaced for members under service every two year limitation. service every two year limitation. 21. Coverage of Eyeglasses Children Under 21 Coverage of Eyeglasses Children Under 21 Contact lenses are covered for certain Years of Age: Years of Age: diagnoses including but not limited to Limited to one pair of eyeglasses per HUSKY unilateral aphakia, keratoconus, corneal Limited to one pair of eyeglasses per HUSKY Health member per two rolling year period, transplant, high anismetropia. Health member per two rolling year period, unless a replacement pair of eyeglasses unless a replacement pair of eyeglasses Photochromatic lenses are covered when during the two-year time period is medically during the two-year time period is medically medically necessary under code V2744. No necessary because of a change in the necessary because of a change in the prior authorization is required. member's medical condition or if the previous member's medical condition or if the previous pair is lost, stolen, or broken. Polycarbonate lenses are covered when pair is lost, stolen, or broken. medically necessary under code S0580. For broken lenses with no change in vision, For broken lenses with no change in vision, the member is eligible to receive a new pair Polycarbonate lenses require an order from the member is eligible to receive a new pair of lenses and frame, even if the new lenses an enrolled Physician, Physician Assistant of lenses and frame, even if the new lenses can be accommodated in the existing frame. (PA), Advanced Practicing Nurse (APRN) or can be accommodated in the existing frame. Optometrist. The order must clearly PLEASE NOTE, this does not apply to “Deluxe PLEASE NOTE, this does not apply to “Deluxe document the medical necessity of the Frames” [refer to section below on Deluxe Frames” [refer to section below on Deluxe requested item. No prior authorization is Frames]. In addition, a spare pair of glasses is Frames]. In addition, a spare pair of glasses is required. not a covered. not a covered High-index; anti-reflective lenses and A spare pair of glasses is NOT covered. A spare pair of glasses is NOT covered. progressive bifocal lenses are not covered Deluxe Frames unless medically necessary. PA is required. Deluxe Frames Procedure code V2799 must be used when Deluxe Frames: Please refer to policy Deluxe Frames: Please refer to policy requesting PA. transmittal PB 2015-102 New Coverage transmittal PB 2015-102 New Coverage Guidelines for Code V2025 Deluxe Frames. Guidelines for Code V2025 Deluxe Frames. Deluxe frames are considered medically Deluxe frames are considered medically necessary for clinical circumstances for necessary for clinical circumstances for
2 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312 HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
children ages 0 to 5 and those members who children ages 0 to 5 and those members who are 6 years of age and older must include one are 6 years of age and older must include one or more correlating diagnosis codes. or more correlating diagnosis codes. Members under 21 years of age that have Members under 21 years of age that have broken lenses that are in a deluxe frame and broken lenses that are in a deluxe frame and have no change in vision the member shall have no change in vision the member shall receive a new pair of lenses that can be receive a new pair of lenses that can be accommodated in the existing deluxe frame accommodated in the existing deluxe frame unless the deluxe frame has been unless the deluxe frame has been compromised. compromised. Deluxe frames will be replaced only if Deluxe frames will be replaced only if medically necessary due to a change in the medically necessary due to a change in the member’s medical condition which results in member’s medical condition which results in the need to provide a new lens that cannot the need to provide a new lens that cannot be accommodated in the existing frame. be accommodated in the existing frame. Eyeglasses with deluxe frames that are lost or Eyeglasses with deluxe frames that are lost or stolen will be replaced for members under stolen will be replaced for members under 21. 21. Contact lenses are covered for certain Contact lenses are covered for certain diagnoses including but not limited to diagnoses including but not limited to unilateral aphakia, keratoconus, corneal unilateral aphakia, keratoconus, corneal transplant, high anismetropia. transplant, high anismetropia. Photochromatic lenses are covered when Photochromatic lenses are covered when medically necessary under code V2744. No medically necessary under code V2744. No prior authorization is required. prior authorization is required. Polycarbonate lenses are covered when Polycarbonate lenses are covered when medically necessary under code S0580. medically necessary under code S0580. Polycarbonate lenses require an order from Polycarbonate lenses require an order from an enrolled Physician, Physician Assistant an enrolled Physician, Physician Assistant (PA), Advanced Practicing Nurse (APRN) or (PA), Advanced Practicing Nurse (APRN) or Optometrist. The order must clearly Optometrist. The order must clearly
3 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312 HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
document the medical necessity of the document the medical necessity of the requested item. No prior authorization is requested item. No prior authorization is required. required. High-index; anti-reflective lenses and High-index; anti-reflective lenses and progressive bifocal lenses are not covered progressive bifocal lenses are not covered unless medically necessary. PA is required. unless medically necessary. PA is required. Procedure code V2799 must be used when Procedure code V2799 must be used when requesting PA requesting PA.
Vision related surgical services – refer to Prior Vision related surgical services – refer to Prior Vision related surgical services – refer to Prior Authorization section of this grid for a list of Authorization section of this grid for a list of Authorization section of this grid for a list of vision related surgical services which require vision related surgical services which require vision related surgical services which require prior authorization. prior authorization. prior authorization. Procedure code V2799 (Vision services, Procedure code V2799 (Vision services, Procedure code V2799 (Vision services, miscellaneous) may be used when requesting miscellaneous) may be used when requesting miscellaneous) may be used when requesting prior authorization (PA) for any medically prior authorization (PA) for any medically prior authorization (PA) for any medically necessary miscellaneous vision service not necessary miscellaneous vision service not necessary miscellaneous vision service not listed on the optician fee schedule. This code listed on the optician fee schedule. This code listed on the optician fee schedule. This code requires PA. The use of miscellaneous code requires PA. The use of miscellaneous code requires PA. The use of miscellaneous code V2799 is not allowed to be used as a V2799 is not allowed to be used as a V2799 is not allowed to be used as a dispensing fee. Code V2799 may be used dispensing fee. Code V2799 may be used dispensing fee. Code V2799 may be used when requesting authorization for services when requesting authorization for services when requesting authorization for services such as a keratoconus lens. such as a keratoconus lens. such as a keratoconus lens.
4 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312 HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
Optometrist/ Professional services of Optometrists and Professional services of Optometrists and Ophthalmologist Ophthalmologists, example, CPT code 92012– Ophthalmologists, example, CPT code 92012– Professional Services: Ophthalmological services: medical Ophthalmological services: medical examination and evaluation) are paid examination and evaluation) are paid according to the rules on the Physician Office according to the rules on the Physician Office and Outpatient fee schedule. These services and Outpatient fee schedule. These services are not subject to the provision of the are not subject to the provision of the eyeglasses limit of one per every two years; eyeglasses limit of one per every two years; however, other limitations may apply. however, other limitations may apply. Professional services provided following a Professional services provided following a surgical procedure should be billed with surgical procedure should be billed with appropriate evaluation and management or appropriate evaluation and management or ophthalmology service code. ophthalmology service code.
Providers should not bill with the surgery Providers should not bill with the surgery procedure code and modifier -55 (post- procedure code and modifier -55 (post- operative management only). When operative management only). When submitting a PA request form for vision- submitting a PA request form for vision- related surgical procedures, you should check related surgical procedures, you should check “Professional /Surgical Services” on the PA “Professional /Surgical Services” on the PA form. Do not check off the box labeled form. Do not check off the box labeled “Vision Care Services” for surgical procedure “Vision Care Services” for surgical procedure codes. codes.
Out of Network Services Non-Covered Non-Covered Non-Covered Providers must be an enrolled CMAP provider Providers must be an enrolled CMAP provider Providers must be an enrolled CMAP provider to be reimbursed for services. to be reimbursed for services. to be reimbursed for services.
Out of State Care Non Emergent Care Requires Prior Non Emergent Care Requires Prior Non Emergent Care Requires Prior Authorization. Authorization. Authorization.
5 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312 HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
Out of Country Care (with Out of the country care (including emergency Out of the country care (including emergency Out of the country care (including emergency the exception of Puerto Rico care) is not a covered benefit (with the care) is not a covered benefit (with the care) is not a covered benefit (with the and USA territories of exception of Puerto Rico and other USA exception of Puerto Rico and other USA exception of Puerto Rico and other USA American Samoa, Federated territories - where emergency care is territories - where emergency care is territories - where emergency care is States of Micronesia, Guam, covered). covered). covered). Midway Islands, Northern Marina Islands, US Virgin Islands)
Procedures requiring Prior Blepharoplasty Blepharoplasty Blepharoplasty Authorization Canthopexy Canthopexy Canthopexy Blepharoptosis repair Blepharoptosis repair Blepharoptosis repair Brow ptosis repair Brow ptosis repair Brow ptosis repair Correction lid retraction Correction lid retraction Correction lid retraction Procedures to correct myopia, refractive Procedures to correct myopia, refractive Procedures to correct myopia, refractive errors and surgically induced astigmatism errors and surgically induced astigmatism errors and surgically induced astigmatism Procedures related to corneal prosthetics Procedures related to corneal prosthetics Procedures related to corneal prosthetics Vision Services, miscellaneous Vision Services, miscellaneous Vision Services, miscellaneous
Translation Services 1-800-440-5071 1-800-440-5071 1-800-440-5071
6 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312 HUSKY Health Program Benefits and Prior Authorization Requirements Grid* Vision Effective: January 1, 2012 Member Services: 800-859-9889 Authorizations: 800-440-5071 Option #2 Authorization Fax: 203-265-3994
Benefit HUSKY A, HUSKY C HUSKY B HUSKY D (LIA)
Benefit EXCLUSIONS • All services of a plastic or cosmetic • All services of a plastic or cosmetic • All services of a plastic or cosmetic nature e.g. hair transplants, nature e.g. hair transplants, electrolysis. nature e.g. hair transplants, This is a general listing of electrolysis. • Services for which prior authorization is electrolysis. those exclusions most • Care out of the country. required and is not obtained. • Care out of the country. applicable to Vision Services and includes but is not • Services for which prior authorization is • Services that are considered to be of an • Services for which prior authorization is limited to the following: required and is not obtained. unproven, experimental or research required and is not obtained. • Services that are considered to be of an nature or cosmetic, social, habilitative, • Services that are considered to be of an unproven, experimental or research vocational, recreational or educational. unproven, experimental or research nature or cosmetic, social, habilitative, • Services that are not medically nature or cosmetic, social, habilitative, vocational, recreational or educational. necessary. vocational, recreational or educational. • Services that are not medically • Services required by third parties, such • Services that are not medically necessary. as school or employers, court ordered necessary. • Services required by third parties, such testing, diagnostics, etc. • Services required by third parties, such as school or employers, court ordered • Services not within scope of as school or employers, court ordered testing, diagnostics, etc. practitioners scope of practice pursuant testing, diagnostics, etc. • Services not within scope of to state law. • Services not within scope of practitioners scope of practice • Services beyond what is necessary for practitioners scope of practice pursuant to state law. treatment. pursuant to state law. • Services beyond what is necessary to • Services not related to illness or • Services beyond what is necessary to treat the medical problems. problems at the time of treatment. treat the medical problems. • Services that have nothing to do with • Services or items for which the provider • Services that have nothing to do with the illness or problem of the visit. does not usually charge. the illness or problem of the visit. • Services or items for which the • Drugs not approved by the FDA. • Services or items for which the provider does not usually charge. provider does not usually charge. • Drugs that are not approved by the • Drugs that are not approved by the FDA. FDA. • Services not usually performed by the • Services not usually performed by the provider. provider.
7 *Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per the CT Department of Social Services. Last Update: 10/15/2020 MMTPE0001-0312