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Vision Services, Policies, and Procedures

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Vision Services, Policies, and Procedures Alaska Medical Assistance Provider Billing Manuals Section I: Vision Services, Policies, and Procedures Prepared By Conduent State Healthcare, LLC Published November 22, 2019 © 2019 Conduent Business Services, LLC. All rights reserved. Conduent™ and Conduent Design™ are trademarks of Conduent Business Services, LLC in the United States and/or other countries. Other company trademarks are also acknowledged. Current Procedural Terminology (CPT) Copyright Notice CPT copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Table of Contents About This Manual .................................................................. I-1 Provider Enrollment ................................................................ I-2 Provider Participation Requirements and Responsibilities ........................ I-2 Provider Participation Requirements for Ophthalmologists ............... I-2 Provider Participation Requirements for Optometrists ...................... I-2 Provider Participation Requirements for Opticians ........................... I-2 Locum Tenens ................................................................................. I-3 Group Enrollment...................................................................................... I-3 Health Professional Group Enrollment ............................................. I-3 Recipient Eligibility .................................................................. I-5 Eligibility Codes ........................................................................................ I-5 Checking Recipient Eligibility for Vision Services ............................. I-5 Service Authorization .............................................................. I-6 Vision Services ....................................................................... I-7 Travel for Medical Care ............................................................................ I-7 Services for Children ................................................................................ I-7 Services for Adults .................................................................................... I-7 Medicaid-Covered Services ...................................................................... I-8 Optical Services ............................................................................... I-8 Prescription Medications .................................................................. I-9 Rendering Providers ...................................................................... I-10 Vision Exam ................................................................................... I-10 Non-covered Services ............................................................................ I-10 Order Submission for Eyeglass Frames and Lenses ............ I-12 Claim Submission ................................................................. I-13 Billing for Contact Lenses ............................................................... I-13 Pricing Methodology ............................................................. I-14 Resource-Based Relative Value Scale ................................................... I-14 Pricing for Services without Established Relative Value Units ................. I-14 i About This Manual The Department of Health and Social Services (DHSS) is the state agency designated to administer the Alaska Medical Assistance program, which includes: Medicaid Denali KidCare (DKC) Chronic and Acute Medical Assistance (CAMA) Unless otherwise specified, references to the Alaska Medical Assistance program, or Alaska Medical Assistance, mean Medicaid, DKC, and CAMA. References to Alaska Medicaid, or Medicaid, mean only Medicaid and DKC. This manual, Section I: Vision Services, Policies, and Procedures is to be used by enrolled ophthalmologists, optometrists, and opticians in conjunction with Section II: Professional Claims Management Section III: General Program Information Updates to this manual will be necessary from time to time as federal and state medical assistance regulations are adopted. As updates are made, each affected segment of the manual will be annotated with the date of the change. Providers will be informed of these updates by remittance advice messages and announcements through Alaska Medicaid Health Enterprise. Previously published manuals are available upon request. Thank you for your participation in the Alaska Medical Assistance program and for the services you provide. Updated 09/11/2018 Section I: Vision Services, Policies and Procedures I-1 Return to TOC Provider Enrollment The following enrollment information is specific to ophthalmologists, optometrists, and opticians. For general enrollment instructions and guidelines, refer to Section III: General Program Information. Provider Participation Requirements and Responsibilities Provider Participation Requirements for Ophthalmologists In addition to the general conditions for participation identified in Section III: General Program Information, ophthalmologists must Have an active license to practice as a physician under AS 08.64 Have an active certification to practice as an ophthalmologist from the American Academy of Ophthalmology Complete, sign, and submit a Physician Provider Addendum Ophthalmologists who wish to enroll as part of a professional group must first enroll individually. For additional information, refer to Health Professional Group Enrollment in this section. Updated 09/11/2018 Provider Participation Requirements for Optometrists In addition to the general conditions for participation identified in Section III: General Program Information, optometrists must Have an active license to practice as an optometrist under AS 08.72 Optometrists who wish to enroll as part of a professional group must first enroll individually. For additional information, refer to Health Professional Group Enrollment in this section. Updated 09/11/2018 Provider Participation Requirements for Opticians In addition to the general conditions for participation identified in Section III: General Program Information, opticians must Have an active license to practice as a dispensing optician under AS 08.71 Opticians who wish to enroll as part of a professional group must first enroll individually. For additional information, refer to Health Professional Group Enrollment in this section. Updated 09/11/2018 Section I: Vision Services, Policies and Procedures I-2 Return to TOC Locum Tenens A provider who is practicing under a temporary or locum tenens permit, license, or authorization, and who is substituting for another provider, being evaluated for permanent employment, or temporarily employed by a facility while it attempts to fill a vacant position must enroll with Alaska Medical Assistance as required to be reimbursed for services rendered. Enrolled locum tenens may receive reimbursement for covered medical services provided to eligible members. To be reimbursed for services rendered, a provider practicing as a locum tenens must: Have an active permit, license, or authorization under AS 08. Enroll as a provider in Alaska Medical Assistance and obtain a Medicaid Contract ID. Enrollment will be approved only for the period on the license or permit. Alaska permits only medical and osteopathic physicians, advanced nurse practitioners, physician assistants, chiropractors, nurses, certified registered nurse anesthetists, and nurse midwives to be a locum tenens. The process usually takes eight weeks to receive the permit. To apply for a permit, contact the Alaska Department of Commerce, Community, and Economic Development’s Division of Corporations, Business and Professional Licensing. Updated 09/11/2018 Group Enrollment Health Professional Group Enrollment In addition to the general conditions for participation identified in Section III: General Program Information, Each member of a health professional group must first enroll individually with the Alaska Medical Assistance program. The following providers may enroll as part of a health professional group and bill directly for services: Physician Chiropractor Advanced nurse practitioner, including nurse midwife Podiatrist-Chiropodist Audiologist Direct-entry midwife Occupational therapist Psychologist Optician Optometrist Physical therapist Speech language pathologist Certified registered nurse anesthetist Section I: Vision Services, Policies and Procedures I-3 Return to TOC Other providers may enroll as part of a health professional group as a rendering provider but may not bill directly for services. Instead, payment for services will be made through the health professional group. These providers include: Physician assistant Occupational therapy assistant Physical therapy assistant Speech language pathology assistant Community Health Aide/ Practitioner (CHA/P) Billing Services in a Health Professional Group Members of a health professional group must bill their services under the group, except when performing services outside the group as part of another practice or job. Updated 09/13 Section I: Vision Services, Policies
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