Provider Notice issued 07/14/06

Prior Approval Changes for Polycarbonate Lenses

Effective with service dates on and after September 1, 2006, the department will change the process for providers requesting prior approval for polycarbonate spectacle lenses. Physicians are affected by this notice only if they participate in ordering eyewear for eligible participants through the department.

The Illinois Department of Corrections’ (DOC) eyeglasses laboratory at Dixon, Illinois, now has the capability to manufacture polycarbonate lenses. The department will authorize the DOC lab to complete these polycarbonate lens orders, instead of authorizing payment to the provider to obtain these lenses from an outside source.

Effective with service dates on and after September 1, 2006, providers who request prior approval for polycarbonate lenses must follow the process outlined below:

• The DPA 1409, Prior Approval Request must be completed. Instructions for completing this form can be found in the Handbook for Providers of Optometric Services, Appendix O-5. HCPCS polycarbonate lens code V2784 must be the requested procedure code, and the eyeglasses prescription should be listed in Box 28. Enter a quantity of 1 or 2, as appropriate, to identify the number of lenses needed.
• The HFS 1443 Provider Invoice must be completed identifying procedure code 92340 for the dispensing fee, and an optometric examination, if applicable.
• The DPA 2803 Optical Prescription Order (OPO) must be completed and the checkbox for polycarbonate lenses must be marked.

All three forms must be submitted to the department together.

If the prior approval request is approved, the OPO will be forwarded to DOC for manufacture of the order and the claim will be processed. The provider and patient will receive a letter of approval.

If the prior approval request is denied, the provider and the patient will receive a denial letter, and the claim and OPO will be returned to the provider. The provider will be responsible for explaining to the patient that the department did not approve the polycarbonate material for the lenses. Lenses may be fabricated of safety thickness plastic through DOC without prior approval. If safety thickness plastic is chosen, the provider will need to submit a claim and indicate safety plastic lenses in the large box titled “Previous Rx/Additional Information” on the OPO.

The patient may choose to purchase polycarbonate lenses through the provider at the patient’s expense. If the patient elects to purchase polycarbonate lenses, the provider will arrange for fabrication of those lenses through an optical lab and the patient will reimburse the provider. Eyeglass frames may still be obtained through the department even if the patient elects to purchase the lenses from the provider.

If procedure code 92340 (dispensing fee) is rejected because of a billing error on a service that has been prior approved, the provider will need to:

• Resubmit the corrected claim,
• Attach a copy of the prior approval letter,
• Attach the OPO;
• Enter the prior approval number from the prior approval letter in the “Previous RX/Additional Information” box on the OPO.
 

Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 877-782-5565.

Anne Marie Murphy, Ph.D.
Administrator
Division of Medical Programs