Member Vision Benefits

BENEFIT

BENEFIT CRITERIA/LIMITATIONS

Routine Eye Exams and Refraction

(Under 21)

• Routine eye exams with refraction as medically necessary.
• The refraction (92015) must be reported separately when using 92XXX.
• Regardless of final diagnosis, a member who presents for an exam with no complaint must be reported as a preventive exam, using the eligible codes as the primary diagnosis.
• CPT II codes 2022F-2033F and 3072F are separately reimbursable when reported for evaluation of diabetic retinopathy. Submit 2022F-2033F for results corresponding to current year findings, or 3072F to report no retinopathy in the prior year. Additional eye exams are subject to retrospective review based on medical necessity criteria.

Copayments

• Children do not have copays.
• Value added services are not subject to copay

OHCA Cost Sharing and Copayments

Medical Services, Surgical Services, and Ocular Injectables

Medically necessary eye care services are covered for members of all ages.

• No prior authorization is required for most services; however, it is required for some. Please see the prior authorization section below for more information.
• All medical and surgical services are subject to Oklahoma Complete Health Utilization Management policies and procedures.
• All claims for ocular injectable drugs should be directed to Centene Pharmacy Services.
• Providers should comply with the Oklahoma Complete Health preferred drug list when prescribing medications for a member.

Eyewear

(Under 21)

• Eligible for up to two pairs of eyeglasses (lenses and frames) per calendar year. Additional corrective lenses and optical supplies are covered when medically necessary. 

Value Added Benefits

(Adults 21+/Specialty Children’s Plan)

Adults age 21+ receive:

•  a complete eye exam with refraction every year (per calendar year, renewing 7/1), and
•  $150 towards the cost of glasses or contact lenses every two years (per calendar years, renewing 7/1).

Foster Care members receive:

•  an additional $100 allowance annually for deluxe frames or contact lenses, and
•  unlimited hardware replacements under the standard Medicaid benefit. 

Value added benefit claims for hardware, contact lenses, fitting and/or dispense must be submitted with the XU modifier on each service line that is intended to be paid under the member annual allowance.

Repairs and Replacements

(Under 21)

• Replacement of or additional lenses and frames are allowed when medically necessary.

Medically Necessary Eyewear

Prior authorization is not required for medically necessary eyewear, however, is subject to retrospective review. Please file with applicable medical diagnosis. Documentation should be maintained in the member’s file of the necessity of the eyewear and/or services provided.

Lenses for Members Under 21

• Progressive lenses, trifocals, photochromic lenses and tints must satisfy the medical necessity standard.

Lenses for All Members

• Bifocal lenses for the treatment of accommodative esotropia.

Low Vision Aids for Members Under 21

• Low vision optical devices including low vision services.

Post-Cataract Eyewear for All Members

• Members who have undergone cataract surgery are entitled to one covered in full pair of standard frames and lenses or contact lenses when medically necessary.
• Use the eligible diagnosis code.

This benefit is allowed once per eye, per lifetime.

Medically Necessary Contact Lenses for all Members

• May be obtained in lieu of eyeglasses when there is no other way to correct a visual defect.
• Contact lenses for treatment of aphakia, keratoconus, following keratoplasty, aniseikonia/anisometropia or albinism, as medically necessary, are covered.
•  Bandage contact lenses are covered for all members when medically necessary.
• Medical diagnosis should be used when submitting claims.

Non-Covered Services

• Any service not listed as a covered benefit within these plan specifics

Prior Authorization

Prior authorization for medical eye services will follow the same process as medical procedures that require prior authorization.

Documentation

Medical records must support medical necessity as applicable.

• Eyeglass documentation includes lens specifications such as lens type, power, axis, prism, absorptive power, and impact resistance.
• Contact lens documentation includes lens specifications such as power, size, curvature, flexibility, and gas permeability.
• Oklahoma Complete Health may require retrospective review of medical records to ensure documentation requirements are satisfied.

Description

Code

Ophthalmological Exam

92002, 92004, 92012, 92014

Refraction

92015

Frames

V2020

Fitting of spectacles

92340 – 92342

Single Vision Lenses

V2100 – V2199

Bifocal Lenses

V2200 – V2299

Trifocal Lenses

V2300 – V2399

Contact Lenses

V2500 – V2599, S0500

Medically Necessary Contact Lens Fitting

92071, 92072

Value Added Hardware Allowance (materials and fit/dispense)

XU Modifier

Replacement of a DME item

RA Modifier

Replacement of a part of DME furnished as part of a repair

RB Modifier

Category II CPT Codes for Diabetic Retinal Exam (DRE) Measure

2022F-2033F, or 3072F prior year findings

Member Eligibility

Check member eligibility via:

•  Secure Web Portal
• Provider Services: 1-833-752-1664