Alaska Medical Assistance Provider Billing Manuals

Section I: Vision Services, Policies, and Procedures

Prepared By Conduent State Healthcare, LLC Published November 22, 2019

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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

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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

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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

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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

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 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

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Recipient Eligibility

All references to recipient mean an individual who is eligible for and receiving assistance under an Alaska Medical Assistance program.

Eligibility Codes

The Department will pay an enrolled ophthalmologist, optometrist, or optician for covered services provided to a recipient who is eligible for Alaska Medical Assistance under one of the following eligibility codes:

Eligibility Codes: Vision Services

Code Category

11 Pregnant Woman (Alaska Healthy Baby Program) 20 No Other Eligibility Codes Apply 21 Chronic and Acute Medical Assistance (CAMA) Coverage Only 24 LTC (300%) Institutionalized 30 Adults with Physical and Developmental Disabilities (APDD) Waiver – Special LTC 31 APDD Waiver 34 APDD Waiver – Adult Public Assistance (APA)/Qualified Medicare Beneficiary (QMB) Eligible 40 Alaskans Living Independently (ALI) Waiver – Special LTC 41 ALI Waiver 44 ALI Waiver – APA/QMB 50 Child under 21 and not in state custody (including subsidized adoptions) 51 Child under 21 and in state custody (including title IV-E Foster Care) 52 4-month Post-MAGI Medicaid Eligibility (increased spousal support) 54 Supplemental Security Income (SSI) Disabled Child 69 Medicare Premium Assistance – APA/QMB Dual Eligibility 70 Intellectual and Developmental Disabilities (IDD) Waiver 71 IDD Waiver 74 IDD Waiver – APA/QMB Eligible 78 Medicare Premium Assistance – SLMB Plus eligible Part B Payment Only 80 Children with Complex Medical Conditions (CCMC) Waiver 81 CCMC Waiver 91 Individualized Supports Waiver (ISW) – Special LTC 92 ISW 93 ISW – Pregnant Woman 94 ISW – APA/QMB Eligible Updated 03/28/2019 Checking Recipient Eligibility for Vision Services

Providers must check recipient eligibility and service limits before submitting orders for optical supplies to Rochester Optical. To confirm recipient eligibility for vision services, use the Recipient Eligibility Inquiry Form-Vision. Providers may also confirm recipient eligibility through the Classic Optical online portal when submitting an order. Updated 11/22/2019 Section I: Vision Services, Policies and Procedures I-5

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Service Authorization

Vision services providers must obtain a service authorization (SA) to receive reimbursement for  Additional eye exams for adults  Specialty eyeglass frames  Second pair of eye glasses for adults  Third pair of eye glasses for children under 21 years of age  Tinted eyeglass lenses  Tinted contact lenses

To request an SA for vision services, use the Vision Service Authorization Request form. Medical justification must be attached to all service authorization requests for vision services. Obtaining an SA does not guarantee payment. Updated 09/11/2018

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Vision Services

Alaska Medical Assistance reimburses enrolled providers for medically necessary services for eligible recipients when delivered, ordered, or prescribed by a provider within the scope of the provider’s license or certification.

Services rendered based on a prescription, order, or referral are reimbursable only if the prescribing, ordering, or referring provider is enrolled as an Alaska Medical Assistance provider. Updated 06/12

Travel for Medical Care

Alaska Medicaid covers transportation and accommodation services when travel is required to receive non-emergent, medically necessary services.

For additional information about non-emergent transportation, including how to request a service authorization, refer to Arranging Patient Travel. Updated 03/28/2019

Services for Children

Recipients under 21 years of age are eligible for the following vision services:  One complete pair of eyeglasses per calendar year  An additional pair of eyeglasses if medically necessary  Subsequent pairs of eyeglasses with a service authorization (SA) based on written medical justification  One complete vision exam per calendar year  Additional vision exams if medically necessary  Vision therapy services

Alaska Medicaid provides limited coverage of contact lenses; for additional information, refer to Optical Services in this section. Updated 09/11/2018

Services for Adults

Recipients 21 years of age and older are eligible for the following vision services:  One complete pair of eyeglasses per calendar year  An additional pair of eyeglasses with a service authorization (SA) based on written medical justification  One complete vision exam per calendar year  Additional vision exams with an SA based on written medical justification

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Alaska Medicaid provides limited coverage of contact lenses; for additional information, refer to Optical Services in this section. Updated 09/11/2018

Medicaid-Covered Services

Optical Services

Contractor for Optical Services

Classic Optical is the Alaska Medicaid contractor for lenses and eyeglass frames. All vision service providers are required to order from this contractor when prescribing eyewear for recipients.

Eyeglass Frames and Lenses

Alaska Medicaid covers eyeglass frames and lenses only if ordered from Classic Optical.

Contact Lenses

Alaska Medicaid covers contact lenses when a recipient is diagnosed with one of the following medical conditions or when another medically necessary reason exists:  Aphakia  Corneal degeneration  Keratoconus  Rejection of an implant  Post cataract surgery

The exam for contact lenses must include:  Slit Lamp Evaluation  Fluorescein examination  Diagnostic evaluation (soft lenses)

Topically administered drugs incidental to the evaluation/exam are not separately reimbursable.

Reimbursement for shipping/handling is reimbursable only if requested and actual shipping/handling charges are indicated on the lens quote.

Repair of Eyeglasses

Damage to a recipient’s eyeglasses should be repaired, when possible. Eyeglasses that cannot be repaired may be replaced if the Medicaid recipient has not exceeded their annual service limit. Submit claims for eyeglass repairs using CPT code 92370. Updated 11/22/2019

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Prescription Medications

Alaska Medical Assistance covers prescription medications when prescribed by an enrolled ophthalmologist or optometrist.

For additional information, refer to the Pharmacy Billing Manual.

Preferred Drug List (PDL)

The Preferred Drug List was developed in an effort to select both clinically sound and cost effective medications for use by those eligible for Alaska Medical Assistance. Applicable prior authorization requirements and maximum quantity limits are indicated on the PDL.

Non-Preferred Drugs

The prescription order for a non-preferred medication must include documentation of medical necessity. Examples of medical necessity include:  Patient Allergy: The patient is allergic to the inert ingredients of the preferred or generic medication  Contraindications: The patient has a history of unacceptable/toxic side effects, contraindication to or an adverse drug-to-drug interaction with the preferred medication  FDA Approved Multiple Indications: The non-preferred medication treats at least one more of the patient’s diagnosed conditions than the preferred medication  Ineffective Treatment: The preferred medication has proven ineffective in treating the specific patient for a diagnosed condition

Brand Name Multi-Source Medications

Alaska Medical Assistance will not pay for a brand-name medication if a therapeutically equivalent generic medication is available unless:  The brand name medication is on the Preferred Drug List; or  The prescriber indicates on the prescription “brand-name medically necessary”; or  The prescriber submits the prescription telephonically with instructions that the brand- name medication is medically necessary and documents it in the recipient’s medical record.

Authorization for Prescribed Medications

Certain medications require prior authorization (PA) before Alaska Medical Assistance covers these medications. Refer to the Prior Authorized Drug List and Interim Prior Authorized Drug List for authorization requirements.

Unless otherwise indicated on the Prior Authorized Drug List or Interim Prior Authorized Drug List, the prescriber must request PA by calling the Magellan Medicaid Administration Clinical Call Center or faxing them a completed PA form. Providers may obtain medication PA forms on the Conduent Pharmacy Updates and Forms page, the DHCS Medication Prior Authorization page, or from the Magellan Medicaid Administration Clinical Call Center.

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Tamper Resistant Prescription Forms

Medications not prescribed by electronic transmission or by oral communication must be written on tamper-resistant paper or printed on plain paper with tamper-resistant features. Tamper-resistant paper or tamper-resistant printing must include at least one industry- recognized feature designed to prevent unauthorized copying of a completed prescription, at least one industry-recognized feature designed to prevent the erasure or modification of information written on the prescription, and at least one industry- recognized feature designed to prevent the use of counterfeit prescription forms. Any one feature may not be used more than once for proof of tamper resistance. Prescriptions must also contain the prescriber’s National Provider Identifier (NPI).

For additional information, refer to the Pharmacy Billing Manual. Updated 09/11/2018

Rendering Providers

A physician, advanced practice registered nurse, or physician assistant enrolled with Alaska Medicaid may receive reimbursement for performing a complete vision examination including a check of refractive state. Updated 09/11/2018

Vision Exam

A clinically indicated complete vision examination with a check of refractive state must include:  A complete case history with ocular, physical, occupational, and medical data  An evaluation of visual acuity with best correction determination  An internal ophthalmoscopy and external check of eyes and adnexa  An evaluation of ocular motility and neurological integrity  A near point subjective examination, dynamic retinoscopy, and subjective refraction If clinically indicated, an ophthalmologist or optometrist should also use a phorometer to test accommodation, convergence, and binocular coordination at far and near distances. If a recipient requires medically necessary contact lenses, a complete vision examination must also include:  A slit lamp evaluation  A fluorescein examination If soft lenses are prescribed, a contact lens examination must also include a diagnostic evaluation. Updated 09/13

Non-covered Services

The services listed below are non-covered for ophthalmologists, optometrists, and opticians. This list is representative of non-covered services and procedures and is not intended to be all-inclusive. For additional non-covered services, refer to Section III: General Program Information.  Optical products provided by a non-contract supplier

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 Any eyeglasses frames or lenses not offered by Alaska Medicaid vision care program  Progressive or no-line lenses  Vision therapy services for recipients 21 years of age or older Updated 09/13

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Order Submission for Eyeglass Frames and Lenses

Orders for eyeglass frames and lenses must be submitted through the Classic Optical online portal or on their paper order form. All orders submitted to Classic Optical require a current, valid diagnosis and the ordering/prescribing provider’s name and NPI number. Orders submitted without this information will not be processed. Updated 11/22/2019

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Claim Submission

Refer to Section II: Professional Claims Management for claim submission instructions and to the CMS-1500 Claim Form instructions for claim form completion instructions specific to Alaska Medical Assistance.

Billing for Contact Lenses

Claims for contact lenses must be submitted  Using the following HCPCS codes: V2510, V2520, V2521, V2522, V2523, or V2599  Using one unit to equal a year’s supply of contacts  With medical justification and a quoted retail price from the manufacturer attached

Claims for contact fitting fees must also be submitted with medical justification attached. Updated 09/11/2018

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Pricing Methodology

Resource-Based Relative Value Scale

Alaska Medical Assistance reimburses ophthalmologists, optometrists, and opticians using the resource-based relative value scale (RBRVS) methodology.

Refer to Section II: Professional Claims Management for additional pricing information. Updated 09/13

Pricing for Services without Established Relative Value Units

Services for which the Centers for Medicare and Medicaid Services (CMS) has not established Relative Value Units (RVU) are manually priced by the department in accordance with 7 AAC 145.050(e).

Refer to Section II: Professional Claims Management for additional pricing information. Updated 09/13

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