Provider Notice issued 03/20/14

Reminder Regarding Service and Supplies Limitations and Record Requirements in the Optometric Program

The purpose of this notice is to remind providers of the department's eye examination and dispensing of eyeglasses requirements, and the importance of maintaining adequate records.

Chapter O-200, Handbook for Providers of Optometric Services states the following regarding eye examinations and the dispensing of eyeglasses:

Eye Exams:

• The department will reimburse for more than one examination per year only when the optometrist or physician documents the need for the additional examination. If more frequent care is medically necessary because of an unusual circumstance, the patient's record must be documented with an explanation of the special circumstances, and the services provided.

• Services, for which medical necessity is not clearly established, are not covered by the department's Medical Programs.

Lenses:

• Lenses are covered only if the power is at least +/- 0.75 diopters, in either the sphere or cylinder component.

• A change in lenses is a covered service only when there is a change of at least +/- 0.75 diopters, in either the sphere or cylinder component.

• Bifocal lenses are covered only if the power of the bifocal addition is +/- 1.00 diopter or more.

• A change in bifocal lenses is covered if the power of the bifocal addition is changed by at least +/- 0.50 diopters.

Limits:

• Adults over 21 years of age and older are limited to one pair of eyeglasses every two years.

• Children less than 21 years of age do not have limits to glasses. Eyeglasses may be replaced as needed without prior approval if there is a change in the prescription as stated above or if they are broken beyond repair, lost, or stolen.

Record Requirements

The department regards the maintenance of adequate records essential for the delivery of quality medical care. Providers must maintain an office record for each patient. The record maintained by the provider is to include the essential details of the patient's condition and of each service or material provided.

The signature of the provider is required for the record of the service/visit to be complete. If there is no signature, then the record is incomplete.

Opticians and optical companies must maintain records adequate to document items dispensed and services provided and to document that eyeglasses and other eye care materials are dispensed only in accordance with a prescription written by a physician or an optometrist. In the absence of proper and complete medical records, no payment will be made, and payments previously made will be recouped. Lack of records or falsification of records may also be cause for a referral to the appropriate law enforcement agency for further action.

Further information regarding the optical program can be found in Chapter O-200, Handbook for Providers of Optometric Services.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565, option 3, option 4.

Theresa A. Eagleson, Administrator

Division of Medical Programs