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Idaho Medicaid Provider Handbook Eye and Vision Services
October 28, 2020 Page i
Table of Contents
Eye and Vision Services ................................................. 1
10.Prior Authorization Requests ................................. 61 10.1. Prior Authorization Requests: Medical Care Unit .......................................... 61
i) New V2025 Frames ...................................................................................... 141
j) Frame Size and Color Chart ........................................................................... 143
Appendix C. Eye and Vision Services, Provider Handbook Modifications ..................... 144
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Eye and Vision Services This section covers all Medicaid vision services provided through Opticians, Optometrists, and Ophthalmologists as deemed appropriate by the Department of Health and Welfare (DHW).
These specialties are identified as vision services throughout this document. Sections of the Idaho Medicaid Provider Handbook applicable in specific situations are listed throughout the
handbook for provider convenience. Handbook sections that always apply to this provider type include the following:
• General Billing Instructions; • General Information and Requirements for Providers; and
• Glossary.
Handbooks can only be used properly in context. Providers must be familiar with the
handbooks that affect them and their services. The numbering in handbooks is also important to make note of as subsections rely on the content of the sections above them.
Example
Section 1.2.3.a The Answer requires the reader to have also read Section 1, Section 1.2 and Section 1.2.3 to be able to properly apply Section 1.2.3.a.
• References are included throughout the handbook for provider and staff convenience.
Not all applicable references have been incorporated into the handbook. Not all references provided are equal in weight.
• Case Law: Includes references to court cases that established interpretations of law that states and providers would be required to follow.
• CMS Guidance: These references reflect various Centers for Medicare and Medicaid Services (CMS) publications that Idaho Medicaid reviewed in the formulation of their
policy. The publications themselves are not required to be followed for Idaho Medicaid
services. • Federal Regulations: These references are regulations from the federal level that
affected policy development. Usually these include the Code of Federal Regulations, the Social Security Act and other statutes. They are required to be followed.
• Idaho Medicaid Publications: These are communications from Idaho Medicaid to providers that were required to be followed when published. These are included in the
handbook for historical reference. The provider handbook supersedes other communications unless the documents are listed in the Department’s Rules, Statutes,
and Policies webpage under policies in Medicaid’s department library.
• Idaho State Plan: The State Plan is the agreement between the State of Idaho and the Centers for Medicare and Medicaid Services on how the State will administer its medical
assistance program. • Professional Organizations: These references reflect various publications of
professional organizations that Idaho Medicaid reviewed in the formulation of their policy. Providers may or may not be required to follow these references, depending on
the individual reference and its application to a provider’s licensure and scope of practice.
• State Regulations: These references are regulations from the state level that affected
policy development. They usually include statute and IDAPA. They are required to be followed.
• Scholarly Work: These references are publications that Idaho Medicaid reviewed in the formulation of their policy. The publications themselves are not required to be followed
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1. Important Contacts The Directory, Idaho Medicaid Provider Handbook contains a comprehensive list of contacts. The following contacts are presented here for convenience.
Gainwell Technologies Gainwell Technologies is Idaho Medicaid’s fiscal agent that handles all claims processing and customer service issues.
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Provider Relations Consultants Gainwell Technologies Provider Relations Consultants help keep providers up-to-date on billing changes required by program policy changes implemented by the Division of Medicaid.
Provider Relations Consultants accomplish this by: • Conducting provider workshops;
• Conducting live meetings for training; • Visiting a provider’s site to conduct training; and
• Assisting providers with electronic claims submission
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Medicaid The Medical Care Unit is Idaho Medicaid’s team that reviews prior authorization requests for additional examinations and some surgical procedures.
The status of a prior authorization request submitted to the Medical Care Unit may be checked
online at the Gainwell Technologies portal under “Authorization Status”, using your NPI. If you have questions on a Denial, click on the Notes, which will explain the reason for the
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National Vision Administrators National Vision Administrators (NVA) reviews prior authorization requests for glasses and contact lenses.
National Vison Administrators, L.L.C.
Attn: Idaho Medicaid Prior Approvals 1200 Route 46 West
Clifton, NJ 07013
Phone: 1 (877) 626-2969 Fax: 1 (888) 483-6830
www.e-nva.com
Providers can view the outcome of their prior authorization request from NVA by logging into their account at www.e-nva.com, or calling 1 (877) 626-2969.
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2. Provider Qualifications
Ophthalmologists An ophthalmologist is a medical or osteopathic doctor who specializes in the eye and vision. Ophthalmologists in any state are eligible to participate in the Idaho Medicaid Program. They
must have a National Provider Identification (NPI). They must be licensed in the state where the services are performed and enrolled as an Idaho Medicaid provider prior to submitting
claims for services. As physicians, ophthalmologists are eligible to be ordering, prescribing, referring and rendering providers.
Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the Physician and Non-Physician Practitioner,
Idaho Medicaid Handbook for all physician allowances and requirements. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more
information on enrolling as an Idaho Medicaid provider.
2.1.1. References: Ophthalmologists
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social
“Physician Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 500. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
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Opticians
An optician is a professional that engages in the practice of filling prescriptions for eyeglasses and contact lenses and does not have prescriptive authority. The services of the optician are
generally bundled into the payment for the services of the optometrist or ophthalmologist. However, opticians can enroll with Idaho Medicaid to bill for certain services. Fitting fees and
dispensing fees in particular are reimbursable. Services provided by an optician working under an enrolled optometrist or ophthalmologist can be billed using the optometrist or
ophthalmologist’s national provider identification (NPI). Opticians enrolling with Idaho
Medicaid must have their own National Provider Identification (NPI).
Providers must follow the guidelines in the provider handbook, in addition to all applicable state and federal rules and regulations. See the General Information and Requirements for
Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho Medicaid provider.
2.2.1. References: Opticians
a) State Regulations “Opticianry.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.010.02. Office
of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.
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Optometrists Only optometrists licensed in the State of Idaho are eligible to participate in the Idaho Medicaid Program. They must have a National Provider Identification (NPI). Optometrists
must enroll as an Idaho Medicaid provider prior to submitting claims for services. Optometrists certified to treat eye disease must include a copy of that certification with their enrollment.
Optometrists are eligible to be ordering, prescribing, rendering and referring providers.
Providers must follow the guidelines in the provider handbook, in addition to all applicable
state and federal rules and regulations. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information on enrolling as an Idaho
Medicaid provider.
2.3.1. References: Optometrists
a) State Regulations “Optometrist Services: Provider Qualifications and Duties.” IDAPA 16.03.09, “Medicaid Basic
Plan Benefits,” Sec. 554. Office of the Administrative Rules Coordinator, Division of Financial
Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
IDAPA 24.10.01, “Rules of the State Board of Optometry,” Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
Practice of Optometry Defined, Idaho Code 54-1501 (2009). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1501/.
State Board of Optometry – Powers and Duties, Idaho Code 54-1509 (2009). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title54/t54ch15/sect54-1509/.
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3. Eligible Participants Participants with Medicaid Basic and Enhanced Plans are eligible to receive vision services based on age restrictions. Providers must check participant eligibility prior to delivery of any
service by calling Idaho Medicaid Automated Customer Service (MACS) at 1 (866) 686-4272; or through the Trading Partner Account on Gainwell Technologies Idaho Medicaid website.
Participants who are covered by Idaho Medicaid but have eligibility restrictions, do not have
vision benefits under Medicaid fee-for-service. These eligibility programs include, but are not limited to:
• Otherwise Ineligible Non-Citizens (OINC);
• Presumptive Eligibility (PE); • Qualified Medicare Beneficiary (QMB) Program only, without another unrestricted
Medicaid eligibility program open; and • Medicare Medicaid Coordinated Plan (MMCP).
When billing for participants enrolled in other benefit plans, refer to General Information and
Requirements for Providers, Idaho Medicaid Provider Handbook for coverage.
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Referrals Vision services performed in the offices of ophthalmologists and optometrists, including the dispensing of eyeglasses, do not require a Healthy Connections (HC) referral. Procedures
performed in an inpatient or outpatient hospital or ambulatory surgery center setting require a referral if the participant is enrolled in HC, Idaho’s Medicaid primary care case management
(PCCM) model of managed care. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for more information about HC requirements.
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Age Restrictions Participants under the age of 21 are eligible for:
• Examinations and vision testing once every 365 days without a prior authorization.
• Eyeglasses every four (4) years without a prior authorization. • Contact lenses with a prior authorization.
• Additional services are covered under EPSDT with a prior authorization if medically necessary to correct or ameliorate defects.
Participants 21 years of age and older are not eligible for routine eye exams, eyeglasses, and contact lenses unless otherwise noted. They are eligible for:
• Examinations and vision testing necessary to monitor a chronic medical condition that may damage the eye such as diabetes. See Appendix A for preapproved diagnoses.
• Services to treat acute conditions that, if left untreated, may cause permanent or chronic damage to the eye. See Appendix A for preapproved diagnoses.
• One pair of eyeglasses or contact lenses following cataract surgery. • Contacts are available with a prior authorization to treat Keratoconus.
• Contact lenses or eyeglasses when necessary to prevent further degradation of vision
due to the existence of a chronic condition. A prior authorization request with supporting documentation must be submitted for review.
3.2.1. References: Age Restrictions
a) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,
House Bill 260 Budget Reductions – Vision Services, Information Release MA11-11
(5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf.
a) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.
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EPSDT Services for Participants Under 21 Services identified as a result of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and which correct or ameliorate a defect will not be subject to the existing amount,
scope, and duration limitations, but will require a prior authorization. The medical necessity for the additional service must be documented. It must be proven safe, effective and accepted
as a medical practice or treatment for the condition being addressed. Additional information for EPSDT including billing requirements for services approved under EPSDT may be found in
the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.
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4. Covered Services and Limitations: Contact Lenses and Eyeglasses
All vision supplies (contact lenses, frames, and lenses,) must have a prescription and be authorized by Medicaid’s contractor National Vision Administrators (NVA). NVA has partnered
with Classic Optical to furnish these supplies. Supplies obtained through any other lab will not be reimbursed by Idaho Medicaid. NVA will bill Medicaid directly for authorized items.
Providers can view, and order vision supplies online from the NVA catalog by logging into the
NVA website (www.e-nva.com). Orders can also be submitted by faxing 1 (888) 522-2022. All orders must contain an authorization number, which may be obtained on the NVA website
or through the NVA Provider Hotline at 1 (877) 626-2969. Authorization numbers are
automatically generated for eligible participants if the item does not require prior approval.
Providers without access to the internet or fax service can mail eyeglasses and contact lens orders with their authorization number to the following address:
Classic Optical
3710 Belmont Ave Youngstown, OH 44505
Some lenses, services and specialty frames require prior authorization/prior approval; please refer to the Prior Authorization Requests section for more information on how to submit a
request.
References: Covered Services and Limitations – Contact Lenses and Eyeglasses
4.1.1. Federal Regulations Prescribed Drugs, Dentures, Prosthetic Devices, and Eyeglasses, 42 C.F.R. Sec. 440.120(d) (1978). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-
4.1.2. State Regulations Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(f) (2018).
Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.
“Prescriptions for Spectacles and Contact Lenses.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.450. Office of the Administrative Rules Coordinator, Division of
Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.
“Vision Services: Provider Reimbursement.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,”
Sec. 785. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
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Contact Lenses Contact lenses will be covered for participants under the age of 21 with extreme myopia or hyperopia requiring a correction equal to, or greater than, minus or plus ten (10.0) diopters
in at least one eye, cataract surgery, keratoconus, anisometropia, or other extreme medical conditions precluding the use of eyeglasses as defined by the Department.
Participants over the age of 21 are eligible for contact lenses when necessary to prevent
further degradation of vision. Medicaid follows Medicare’s LCD (L33793) for determining
coverage.
Orders for contacts should be made through Classic Optical by completing the Contact Lens Order Form (available for download at www.e-nva.com after login). All contact lenses (HCPCS
V2500 – V2599) require a prior authorization from NVA; please refer to the Prior Authorization Requests section for more information on how to submit a request.
4.2.1. References: Contact Lenses
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration,
House Bill 701 Budget Reductions – Changes in Vision Benefits, Information Release MA10-
21 (12/01/2010). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/IR%20MA10-
21%20HB701%20Budget%20Reduction%20-%20Vision.pdf.
c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of
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d) State Regulations “Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02.c. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
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4.2.2. Contact Lens Bandage Idaho Medicaid covers the fitting of contact lens for treatment of ocular surface disease for children and adults. The CPT® code 92071 does not require a prior authorization or KX
modifier. The payment for the actual lens is included within the payment for 92071.
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4.2.3. Contact Lenses for Keratoconus Available for all ages, gas permeable contact lenses (HCPCS V2510 or V2511) and custom lenses (HCPCS V2599 with quantity 1 or 2) require a Prior Authorization Request. Prior
authorization requests should include the contact lens prior approval form and physician documentation to support the diagnosis of Keratoconus. When requesting custom lenses, note
on the request form “custom made contacts for keratoconus, diagnosis H18.81.”
If you need a fitting kit, contact NVA’s partner, Classic Optical, to discuss the type of kit
and/or specifications needed for special fit, custom-made contact lenses. You may reach Classic Optical at 1-888-522-2020 and a customer service representative will assist you, or
by faxing a request to 1 (888) 522-2022. Fitting kits for Rose K, Jupiter, Custom Stable, McGuire or Dyna Intra Limbal gas permeable lenses are available. Kits are available free of
charge with a prepaid return label. After the trial fit, please clean and disinfect the lenses before returning the kit.
There is a warranty period on custom lenses, during which time you may exchange the
contacts. A new authorization is not needed if the contacts are under warranty. This is a no
charge “exchange in place” replacement. The original unusable contact lenses must be returned to Classic Optical.
a) References: Contact Lenses for Keratoconus
i) Idaho Medicaid Publications “Attention: Optometrists, Ophthalmologists and Other Vision Service Providers.” MedicAide Newsletter, July 2011,
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Eyeglass Frames Participants under the age of 21 are eligible for a frame (HCPCS V2020) once every four years without a prior authorization. A booklet of available frames is available in Appendix B.
Early Periodic Screening, Diagnosis and Treatment services (EPSDT) may allow for coverage earlier than the four-year limitation with a prior authorization from NVA and documentation
of: • The lenses or frame being lost, damaged beyond use, or the current frames having
been outgrown; or
• New lenses being necessary, and the prescription cannot be accommodated in lenses which fit the existing frames.
Participants over the age of 21 are only eligible for eyeglasses once every four years, when
necessary to prevent further degradation of vision. Frames are only covered under HCPCS V2020. A prior authorization from NVA is necessary; please refer to the Prior Authorization
Request section for more information on how to submit a request. Replacement of broken, lost, or missing glasses is the responsibility of the participant.
NVA will replace frames which break due to normal wear in the first 90 days. If repairs are needed after 90 days, the provider may bill Medicaid for the repairs using CPT® code 92370.
If a participant has a history of repeatedly breaking frames, the vision provider should repair the frame, or request a sturdier frame (HCPCS V2020).
4.3.1. References: Eyeglass Frames
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration,
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c) Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.
“Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid,
Attachment 4.19-B. Department of Health and Welfare, State of Idaho.
d) State Regulations “Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of
“Frames.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
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4.3.2. Deluxe (Specialty) Frames Deluxe (Specialty) frames (HCPCS V2025) require a prior authorization request to NVA with documentation of a medical condition that cannot be met by other frames. They are not
available as a replacement for frequent breakage of V2020 frames.
Children under the age of three (3) may qualify with documentation of multiple V2020 frames trialed that do not fit. At a minimum these frames should be considered:
• Cutie metal (32-15-115, 32-15-120);
• L8005 (36-17-140, 38-17-140, 40-18-140); and • Mainstreet 415 plastic with cable temple (33-20-115, 36-20-120, 39-20-125).
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Eyeglass Lenses Participants under the age of 21 are eligible for one set of single vision or bifocal lenses once every four (4) years without a prior authorization, except when there is a minimum Rx of 0.50
diopter in at least one eye considering both the spherical and cylindrical prescription. Early Periodic Screening, Diagnosis and Treatment services (EPSDT) may allow for coverage earlier
than the four-year limitation with a prior authorization from NVA and documentation of: • A major visual change that is equal or greater than plus or minus 0.50 diopter in one
eye considering both the spherical and cylindrical prescription; or
• The lenses or frame being lost, damaged beyond use, or the current frames having been outgrown.
Participants over the age of 21 are only eligible for eyeglasses once every four years, when
necessary to prevent further degradation of vision. A prior authorization from NVA is necessary; please refer to the Prior Authorization section for more information on how to
submit a request. Replacement of broken, lost, or missing glasses is the responsibility of the participant.
All plastic and polycarbonate lenses must have scratch resistant coating.
4.4.1. References: Eyeglass Lenses
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration,
“Definitions of Services, Institutions, Etc.” Social Security Act, Sec. 1861(r) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title18/1861.htm.
Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office,
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“Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment 4.19-B. Department of Health and Welfare, State of Idaho.
d) State Regulations “Eye Examinations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.01.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
“Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06.
Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
“Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.02. Office of the
Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
“Replacement Lenses.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.03. Office
of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
“Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06.b. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
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4.4.2. Aspheric Lenses Aspheric lenses (HCPCS V2410, V2430 and V2499) are covered with a prior authorization
from NVA and documentation of a plus 8.0 diopter reading or greater.
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4.4.3. High Index Lens Material High Index lens material is covered with a prior authorization from NVA and documentation of:
High Index Lens Material
HCPCS Criteria for Coverage
V2782 Minus 4.0 diopter to minus 9.75 diopter prescription in at least one eye. Both spherical
and cylindrical prescription may be added together for the same eye if both numbers are a minus (-).
V2783 Minus 10.0 diopter or higher prescription in at least one eye. Both spherical and
cylindrical prescription may be added together for the same eye if both numbers are a minus (-).
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4.4.4. Lenticular Lens Material Lenticular Lens Material (HCPCS V2115, V2121, V2215, V2221) is covered with a prior authorization from NVA and documentation of equal to, or greater than, plus or minus 10.0
diopter prescription in at least one eye. Both the spherical and cylindrical prescription may be added together for the same eye if both numbers are a plus (+) or a minus (-).
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4.4.5. Photochromatic/Transition Lenses Photochromatic/Transition lenses (HCPCS V2744) are not covered per IDAPA 16.03.09, “Medicaid Basic Plan Benefits.” A prior authorization request may be submitted for tinted
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4.4.7. Tinted Lenses Tinted lenses (HCPCS V2745) require a prior authorization from NVA with supporting documentation of medical necessity such as albinism, or other medical conditions or
ophthalmologic diseases which cause photophobia. Other conditions might be aniridea, aphakia, migraine headaches, retinitis pigmentosa, severe blepharospasm, corneal injury, or
congenital abnormalities. Photophobia alone does not suffice for approval of tinted lenses. Tint can be applied to a solid lens or as a gradient to the lens and based upon a percentage.
A medical diagnosis must also be provided. Lenses are not covered for cosmetic or
convenience purposes.
Requests for a special therapeutic rose-colored tint F41 may be submitted under V2799.
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Eye Glasses for Cataract Surgery One pair of eyeglasses is covered for all ages following a recent cataract surgery. The Department follows the Medicare Coverage Determination Guidelines for cataract surgery. A
prior authorization from NVA is necessary, unless the participant has Medicare primary. The prior authorization request must include the date of the cataract surgery, eye(s) treated and
the surgeon’s name.
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Miscellaneous Supply All miscellaneous supply codes (HCPCS V2599, V2799) require a prior authorization from NVA. Documentation must include medical necessity, and why the request would be the least costly
means of meeting the participant’s needs.
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Fitting Fee/Dispensing Fee Fitting or dispensing of glasses or contact lenses (CPT® 92071, 92072 and 92310–92317) does not require a prior authorization. The dispensing provider may bill Idaho Medicaid for
fitting/dispensing when the new frames or lenses are covered by Medicaid and ordered from NVA.
4.7.1. References: Fitting Fee/Dispensing Fee
a) State Regulations “Fitting Fees.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.05. Office of the
Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
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Non-Covered Services
Participants who desire additional features non-covered by Medicaid due to not being medically necessary may pay for them separately. The Medicaid contractor will bill the
provider separately, and the provider may bill their usual and customary charge to the participant. If the participant cannot adapt to new lenses that were not originally covered by
Medicaid, the participant is responsible for any additional charges. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for
information on billing a participant.
4.8.1. References: Non-Covered Services
a) State Regulations “Non-Covered Items.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.06. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
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5. Covered Services and Limitations: Examinations and Diagnostics
Idaho Medicaid requires the appropriate eye exam procedure code to be billed for routine eye exams. Instrument-based ocular screening (photo screening) may be used as part of a vision
exam but is not separately reimbursable unless performed by a physician or a non-physician practitioner. If the participant requests a copy of their prescription, it must be provided to the
participant. See Eligible Participants for age and plan restrictions.
Vision exams and testing are allowed once every 365 days without a prior authorization for participants under the age of twenty-one (21). Additional exams and testing must be prior
authorized by the Medical Care Unit. See Prior Authorization (PA) Requests for information on
submitting a request.
Examinations and vision testing are only covered for participants over twenty-one (21) when necessary to monitor a chronic medical condition that may damage the eye such as diabetes
or for acute conditions that, if left untreated, may cause permanent or chronic damage to the eye. A list of preapproved chronic and acute condition diagnosis codes is listed in Appendix A,
no prior authorization is necessary. A KX modifier must be used if an examination does not pertain to a preapproved diagnosis. Supporting medical documentation is required to be
attached to the claim.
References: Covered Services and Limitations: Examinations and Diagnostics
5.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(a)(12) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,
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House Bill 260 Budget Reductions – Vision Services, Information Release MA11-11
(5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf.
5.1.3. Idaho State Plan Alternative Benefit Plan. Division of Medicaid. Department of Health and Welfare, State of Idaho.
5.1.4. State Regulations “Eye Examinations.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 782.01.a. Office
of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
“Eyeglasses Under EPSDT.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.06.
Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(d)(ii) (2018). Idaho State Legislature,
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New and Established Patient Exams A new patient is one who has not received any professional services for the last three (3) years from the physician or another physician of the same specialty who belongs to the same
group practice. An established patient is one who has received professional services within the last three (3) years.
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Comprehensive Ophthalmological Services A comprehensive visual examination includes the following professional and technical vision services:
• Complete visual system examination; • Medical history review;
• General medical observation; • External and ophthalmoscopic examination;
• Determination of best-corrected visual acuity;
• Gross visual fields; • Basic sensorimotor examination with cycloplegia or mydriasis;
• Tonometry; • Refractive state;
• Initiation of diagnostic and treatment programs; and • Other examination techniques that may be included in the fee for the comprehensive
exam are: o Biomicroscopy;
o Corneal sensitivity;
o Corneal staining; o Fundus examination;
o Keratometry; o Retinoscopy;
o Slit lamp viewing, tear testing; and o Treatment programs.
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Intermediate Ophthalmological Services
The participant is eligible for intermediate services if they do not require a comprehensive service for a routine eye exam or are being examined for a chronic, but stable, condition (i.e.,
known cataract). Intermediate Ophthalmological Services include medical examination and evaluation, with initiation or continuation of diagnostic and treatment program. This includes
the following: • Medical history review;
• General medical observations;
• External ocular and adnexal examination; • Diagnostic procedures such as ophthalmoscopy, biomicroscope and tonometry along
with a treatment regimen; and • Mydriasis.
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Evaluation and Management Evaluation and Management (E/M) Codes are used to report services provided in the physician’s office related to eye injury or diseases affecting the eye. These codes do not
require a prior authorization. Providers are required to use either the 1995 or 1997 evaluation and management (E&M) documentation guidelines to document E&M office and outpatient
visits. Modifications to these guidelines include: • Elimination of the requirement to document the medical necessity of a home visit
instead of an office visit;
• Focusing documentation on changes and persisting problems since the last visit for established patients, provided the physician or non-physician practitioner indicate in
the record the patient’s medical record was reviewed and updated if necessary; and • Clarification that practitioners do not need to re-enter the participant’s chief complaint
and history into the medical record if ancillary staff or the participant have already updated it. The practitioner only needs to indicate in the medical record that the
information has been reviewed and verified.
5.5.1. References: Evaluation and Management
a) CMS Guidance 1995 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services, Department of Health and Human Services,
Evaluation and Management Services. Centers for Medicare and Medicaid Services,
Department of Health and Human Services, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-
guide-ICN006764.pdf.
“Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule
(MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List.” MLN Matters
MM11063, November 2018, Centers for Medicare and Medicaid Services, Department of Health and Human Services, https://www.cms.gov/Outreach-and-Education/Medicare-
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Fundus Photography Fundus examinations are included in the reimbursement for intermediate and comprehensive vision examinations. Fundus photography is not reimbursable by Idaho Medicaid for screening
purposes, or diagnosis of vision conditions such as myopia, hyperopia, or astigmatism. Photography is only separately reimbursable when monitoring potential progression of a
disease, or for guidance in evaluating the need for a specific treatment or intervention. If it will not guide future treatment, it is not medically necessary. When performed an
interpretation and report must be included in the medical record, regardless of a modifier 52.
5.6.1. References: Fundus Photography
a) Idaho Medicaid Publications “Attention Vision Providers: Fundus Photography, CPT 92250.” MedicAide Newsletter, March 2017,
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Refraction Procedure Medicaid’s reimbursement rate for exams includes determination of refractive state and should be part of every intermediate or comprehensive exam. The Department will not pay
for an exam code and refraction code billed for the same date of service.
For participants under the age of 21, providers may bill a refraction (CPT® 92015) without the exam once a year. Determination of refractive state includes specification of lens type, lens
power, axis, prism, absorptive factor, impact resistance, interpupillary distance and other
necessary factors.
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Tonometry Tonometry (CPT® 92100) is considered included within a comprehensive visual exam. If an additional separate tonometry is needed, Medicaid will allow one (1) additional tonometry
within the same 365-day period as the comprehensive exam. This limitation does not apply to participants receiving ongoing treatment for glaucoma.
5.8.1. References: Tonometry
a) State Regulations “Tonometry.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 502.03. Office of the
Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
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6. Covered Services and Limitations: Pharmaceuticals Optometrist and Ophthalmologist, with the appropriate credentials, are eligible for reimbursement for administering pharmaceuticals in an office setting through Gainwell
Technologies. Pharmaceuticals provided to participants for home-use must be billed through Magellan Healthcare. All pharmaceuticals must meet any coverage or criteria requirements to
be eligible for reimbursement.
References: Covered Services and Limitations: Pharmaceuticals
6.1.1. State Regulations “Board Certification of Optometrist Authorized to Obtain and Use Pharmaceutical Agents.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec.600. Office of the
Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.
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7. Covered Services and Limitations: Surgery and Procedures
Providers should follow the Physician and Non-Physician Practitioner, Idaho Medicaid Provider Handbook for criteria and billing requirements on surgeries. Optometrists also must follow the
Optometrists Performing Procedures section of this handbook.
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Optometrists Performing Procedures In addition to those requirements optometrists must append modifier 55 to CPT® codes within the range 65XXX through 68XXX. This indicates that the optometrist provided post-op care
only. There are a limited number of codes that are within the full scope of the optometrist to provide that do not require a 55 modifier.
Codes for Optometrists That Do Not Require Modifier 55
CPT® Description
65205 Removal of foreign body, external eye; conjunctival superficial
65210 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral non-perforating
65220 Removal of foreign body, external eye; corneal, without slit lamp
65222 Removal of foreign body, external eye; corneal, with slit lamp
65430 Scraping of cornea, diagnostic, for smear and/or culture
65435 Removal of foreign body, intraocular; from anterior chamber of eye or lens
67700 Blepharotomy, drainage of abscess, eyelid
67820 Correction of trichiasis; epilation, by forceps only
67840 Excision of lesion of eyelid (except chalazion) without closure or with simple
direct closure
67850 Destruction of lesion of lid margin (up to 1 cm)
67938 Removal of embedded foreign body, eyelid
68020 Incision of conjunctiva, drainage of cyst
68040 Expression of conjunctival follicles (e.g., for trachoma)
68761 Closure of the lacrimal punctum; by plug, each
68801 Dilation of lacrimal punctum, with or without irrigation
68840 Probing of lacrimal canaliculi, with or without irrigation
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Blepharoplasty Idaho Medicaid covers blepharoplasty, surgery to remove excess tissue of the eyelids when medically necessary. Cosmetic blepharoplasty, which is performed to improve a patient’s
appearance, is considered is not covered. Medical necessary indications include procedures to improve abnormal function. Upper blepharoplasty or repair of blepharoptosis may be
considered functional in nature when excess upper eyelid tissue or the upper lid position produces functional complaints, such as impairments to the field of vision.
Participants must meet the Medicare criteria found in the Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift (L36286) established by Medicare’s
contractor, Noridian Healthcare. Participants under the age of twenty-one may be eligible for additional coverage beyond the LCD criteria under Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) guidelines with a prior authorization. EPSDT coverage may be available for cases where there is a deformity or trauma necessitating reconstruction.
7.2.1. References: Blepharoplasty
a) CMS Guidance Local Coverage Determination (LCD): Blepharoplasty, Eyelid Surgery, and Brow Lift
d) State Regulations “Medical Necessity (Medically Necessary).” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,”
Sec. 011.16 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
“Services Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.04 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
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Corneal Transplants Idaho Medicaid may cover corneal transplants when efficacy has been demonstrated for the underlying condition. See the Organ Transplant section of the Hospital, Idaho Medicaid
Provider Handbook for information about coverage of corneal transplants and requirements.
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Lasik Eye surgeries for curing or alleviating myopia are non-covered by Idaho Medicaid. Lasik is not covered under Early and Periodic Screening, Diagnosis and Treatment (EPSDT) as it is not the
least costly option for alleviating the participant’s condition.
7.4.1. References: Lasik
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,
Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4-
sec440-225.pdf.
b) State Regulations
“Services Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.04 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(m) Office of the Administrative Rules Coordinator, Division of
Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
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Photorefractive Keratectomy Eye surgeries for curing or alleviating myopia are non-covered by Idaho Medicaid. Photorefractive keratectomy is not covered under Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) as it is not the least costly option for alleviating the participant’s condition
7.5.1. References: Photorefractive Keratectomy
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,
Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4-
sec440-225.pdf.
b) State Regulations
“Services Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 882.04 Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.02(m) Office of the Administrative Rules Coordinator, Division of
Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
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8. Covered Services and Limitations: Therapy Services Optometrists and Ophthalmologists are eligible providers of physical therapy services in their offices. Covered services must meet all occupational and physical therapy requirements to be
reimbursable.
References: Covered Services and Limitations – Therapy Services
8.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,
Optional Services, 42 C.F.R. Sec. 440.225 (1995). Government Printing Office, https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol4/pdf/CFR-2018-title42-vol4-
sec440-225.pdf.
8.1.2. State Regulations “Payment Availability.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554.01. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
“Physical Therapy Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 502.04. Office of the Administrative Rules Coordinator, Division of Financial Management, State of
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Eye Exercise Therapy See the Vision Therapy section.
Interactive Metronome Therapy See the Visual Processing Therapy section.
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Vision Therapy According to the American Optometric Association (AOA), vision therapy is “a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the
doctor to develop, rehabilitate, and enhance visual skills and processing.” Exercises are usually weekly over several months performed in the optometric office and supplemented
with a prescribed concurrent at-home reinforcement program. The AOA also states that, “The vision therapy program is based on the results of a comprehensive eye examination or
consultation, and takes into consideration the results of standardized tests, the needs of the
patient, and the patient’s signs and symptoms. The use of lenses, prisms, filters, occluders,
specialized instruments, and computer programs are an integral part of vision therapy.”
8.4.1. Vision Therapy: Provider Qualifications Vision therapy is only reimbursable when administered by:
• An optometrist; or
• An occupational therapist or physical therapist that is; o Under the direct supervision of an optometrist;
o Trained in vision therapy by the supervising optometrist; and
o Following all requirements in the Therapy Services – Occupational and Physical, Idaho Medicaid Provider Handbook, including billing under their own or their
group NPI.
Direct supervision requires the optometrist to be physically available at the time and location of the services. Supervision of each therapist and each participant’s case must be
documented. The supervising optometrist should review each case at daily or weekly intervals, and the plan of care must be reviewed and updated by the supervising optometrist
as needed and at least every eight (8) weeks.
8.4.2. Vision Therapy: Eligible Participants Vision Therapy is excluded from coverage under IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” however, it may be available under the Children’s Medicaid program with a prior
authorization through EPSDT for children 7-21 years of age with a diagnosis of:
Diagnoses Covered for Vision Therapy
ICD-10-CM Description
H51.11—H51.12 Convergence insufficiency and excess
H52.521—H52.523 Paresis of accommodation
H52.531—H52.533 Spasm of accommodation
Diagnosis must be established with quantifiable measurements and symptoms. Vision therapy
is not considered a medically necessary treatment for asymptomatic conditions, autism, behavioral vision therapy, reading or learning disorders including, but not limited to dyslexia.
8.4.3. Vision Therapy: Coverage and Limitations Vision therapy is only reimbursable with a prior authorization, for an eligible participant when
provided by an eligible provider, and with adherence to all Medicaid requirements. All vision therapy services should be billed under CPT® 92065 (Orthoptic and pleoptic training). Therapy
is covered initially for one (1) hour per week for twelve (12) weeks, but more may be requested at the conclusion of the twelve (12) weeks with documentation of achieved progress
and continued need. Sessions are to be one-on-one for an hour each, but half hour sessions may be authorized if the participant is unable to tolerate a full hour of treatment.
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A concurrent at-home reinforcement program is the standard of care and considered medically necessary for treatment to continue. The participant or their caregiver must keep a training
log. If the reinforcement program has not started by the second week of therapy, the provider must document the reason in the therapy record.
Only the following places of service are covered for vision therapy:
• 11 – Office; • 19 – Off Campus – Outpatient Hospital; and
• 22 – On Campus – Outpatient Hospital.
Vision therapy is not covered for group therapy, telehealth or with home computer programs.
At the end of the initial authorization if sufficient progress has not been achieved, requests for additional visits will be denied as other interventions, or a referral to an ophthalmologist,
may be more appropriate.
8.4.4. Vision Therapy: Additional Documentation Providers must maintain documentation as required in the General Information and
Requirements for Providers, Idaho Medicaid Provider Handbook. Additionally, documentation
must include: • Results from an exam/evaluation completed by the qualified optometrist;
• Convergence Insufficiency Symptom Survey results (>16), if available; • Baseline accommodative scores, if applicable;
• Baseline near point of convergence; • Baseline positive fusional vergence at near (PFV);
• An individualized plan of care that includes: o Qualified diagnosis and symptomology;
o Measurable short and long-term treatment goals;
o A plan to train the parents and child for a concurrent in-home exercise program;
and
o A review and update every eight weeks by the supervising optometrist with:
▪ Updated test results; and
▪ Progress toward treatment goals; • Treatment notes for each session that include:
o Date of treatment;
o Total time in minutes for treatment of CI or accommodation (time in and out); o Account of activity and results;
o Objective measurement of the participant’s response to the services; and o The name, signature and credentials of the person administering the therapy;
• Provider qualifications;
• Supervision documentation completed at daily or weekly intervals;
• If a scheduled session does not occur as scheduled, the provider must indicate in their
records the reason the plan of care was not followed; • Compliance with the concurrent at-home reinforcement program such as a daily log
signed and dated by an adult participant or caretaker; and
o If not started by the second week of therapy, the provider must document the
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1811. Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.
Requests may also be mailed to:
Attn: EPSDT Request
IDHW – Division of Medicaid P.O. Box 83720
Boise, ID 83720-0036
The status of a prior authorization request may be checked by providers online at the Gainwell
Technologies portal under “Authorization Status”, using your NPI.
Requests for prior authorization to initiate treatment should include: • A completed EPSDT Request Form;
• CPT® Code 92065 with prescribed amounts, frequency and duration; • Results from an exam/evaluation completed by the qualified optometrist within the
past three (3) months;
• Convergence Insufficiency Symptom Survey results (>16), if available; • Baseline accommodative scores if the child has one of the specified disorders of
accommodation; • Baseline near point of convergence;
• Baseline positive fusional vergence at near (PFV); • The diagnosis codes that qualify the child for vision therapy;
• The credentials of the person administering the therapy; and • An individualized plan of care that includes:
o Qualified diagnosis and symptomology;
o Measurable short and long-term treatment goals; and o A plan to train the parents and child for a concurrent in-home exercise program.
Requests for prior authorization to continue treatment after twelve (12) weeks should include:
• A completed EPSDT Request Form. • CPT® Code 92065 with prescribed amounts, frequency and duration;
• Current progress evaluation by supervising optometrist including updated test results, progress toward treatment goals, and confirmation of continuing medical
direction and evaluation;
• Documentation of compliance with the concurrent at-home reinforcement program such as a daily log signed and dated by an adult participant or caretaker; and
• Treatment notes for each session that include: o Date of treatment;
o Total time in minutes for treatment of CI or accommodation (time in and out); o Account of activity and results;
o The name and credentials of the person administering the therapy; and o Subject and objective narratives, if applicable; and
• Updated individualized plan of care.
8.4.6. References: Vision Therapy
a) Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,
b) Idaho Medicaid Publications “Attention: Vision Providers and Occupational Therapists.” MedicAide Newsletter, May 2014, https://www.idmedicaid.com/MedicAide%20Newsletters/May%202014%20MedicAide.pdf.
c) Idaho State Plan “Excluded Services.” Enhanced Alternative Benefit Plan. Division of Medicaid, Attachment
3.1-A. Department of Health and Welfare, State of Idaho.
d) Professional Organizations “Definition of Optometric Vision Therapy.” American Optometric Association, April 2009,
“EPSDT Services.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 880—889. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
Medical Assistance Program — Services to Be Provided — Experimental Services or Procedures Excluded, Idaho Code 56-209d (2005). Idaho State Legislature,
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Visual Processing Therapy Visual Processing Therapy (VPT), or Interactive Metronome® therapy, is considered experimental and investigational by Idaho Medicaid and is a non-covered service. This
determination was made due to the lack of statistically significant research after a review of the literature. Services determined to be experimental and investigational are not eligible for
coverage through EPSDT.
8.5.1. Literature Review Beckelhimer et al. (2011)1 was a study of two stroke patients and the use of the interactive metronome in addressing motor performance. The study provides some preliminary evidence
suggesting efficacy of computer-based rhythm and timing in chronic stroke. However, the sample size was insufficient in this study to demonstrate applicability to any population. It
was not included in determining if visual processing therapy is a medically necessary service.
Shaffer et al. (2001)2 was a study of the effects of the interactive metronome on 56 boys age 6-12 with ADHD. Due to the lack of sample size this study was not acceptable for inclusion in
demonstrating visual processing therapy is a medically necessary service. The sample size
was insufficient to show applicability to a wider population. The study had additional issues that prevented it from adequately controlling for the placebo effect and too many variables
to allow demonstration of causation between the treatment and the benefits.
Park and Choi’s research (2017)3 was a case study of the effects of the interactive metronome on two male children ages four and six with ADHD. The sample size was insufficient in this
study to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.
Leisman and Melillo’s (2010)4 study of 109 male children 6-11 years of age addresses the apparent lack of motor coordinative abilities of ADHD. The sample size was insufficient in this
study to demonstrate applicability to the population, as well as harms and benefits from the treatment. The author’s conclusion was that a future large scale clinical trial would be
beneficial.
Gorman (2003)5 was not acceptable for inclusion due to being unpublished. Research must be peer-reviewed before it can be considered by Idaho Medicaid for inclusion in review.
Teicher (2019)6 was not acceptable for inclusion due to being unpublished. Research must be peer-reviewed before it can be considered by Idaho Medicaid for inclusion in review. The white
paper did state support for designation as an experimental/investigational service in that, “Research is ongoing and will continue to investigate and further define the host of
neurobiological changes associated with IM and BB training as well as their relationship to clinical outcome for individuals with ADHD.”
Roseblum and Regev (2013)7 was a study of the interactive metronome on 42 children ages
7-12 with developmental coordination disorders. The sample size was insufficient in this study
to demonstrate applicability to any population. It was not included in determining if visual processing therapy is a medically necessary service.
There is some low-quality evidence showing the possibility of benefit, however, the studies’
lack of applicable sample size and bias prevent them from supporting the service for being considered for coverage. The reviewed studies did not include a control group of individuals
not receiving the therapy or alternative treatments. Additional evidence-based and peer reviewed research is needed with adequately sized control and variable groups and long-term
evidence of benefits and harms before these therapies can be reconsidered for coverage.
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8.5.2. References: Visual Processing Therapy
a) Idaho Medicaid Publications “Visual Processing Therapy.” MedicAide Newsletter, November 2020, https://www.idmedicaid.com/MedicAide%20Newsletters/November%202020%20MedicAide.
pdf.
b) Scholarly Work 1. “Computer-Based Rhythm and Timing Training in Severe, Stroke-Induced Arm
Hemiparesis” American Journal of Occupational Therapy, January-February 2011;
Vol. 65, No. 1, pages 96-100, Sarah C. Beckelhimer, Ann E. Dalton, Charissa A. Richter, Valerie Hermann, Stephen J. Page,
https://pubmed.ncbi.nlm.nih.gov/21309376/.
2. “Effect of interactive metronome training on children with ADHD.” American Journal of Occupational Therapy, March-April 2001; Vol. 55, No. 2, pages 155-162, R.J.
3. “Effects of interactive metronome training on timing, attention, working memory, and processing speed in children with ADHD: a case study of two children.” The
Journal of Physical Therapy Science, December 2017; Vol. 29, No. 12, pages 2165-2167, Yun-Yi Park, MSC, OT, Yu-Jin Choi, PhD, OT,
https://pubmed.ncbi.nlm.nih.gov/29643596/.
4. “Effects of motor sequence training on attentional performance in ADHD children.”
International Journal on Disability and Human Development, December 2010; Vol. 9, No. 4, Gary Leisman, Robert Melillo,
7. “Timing abilities among children with developmental coordination disorders (DCD) in
comparison to children with typical development.” Research in Developmental Disabilities, January 2013; Vol. 34, No. 1, pages 218-227, Sara Rosenblum, Noga
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c) State Regulations “Medical Necessity (Medically Necessary).” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 011.16 Office of the Administrative Rules Coordinator, Division of Financial
Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
“Experimental Treatments or Procedures.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 390.03 Office of the Administrative Rules Coordinator, Division of Financial
Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
Medical Assistance Program – Services to be Provided, Idaho Code 56-255(5)(a) (2018).
Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-255/.
“Types of Treatments and Procedures Not Covered.” IDAPA 16.03.09, “Medicaid Basic Plan
Benefits,” Sec. 390.02(g) Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho,
“Vision Therapy.” IDAPA 24.10.01, “Rules of the State Board of Optometry,” Sec. 010.03
Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/24/241001.pdf.
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9. Documentation Requirements Documentation requirements applicable in specific situations are listed throughout the handbook for provider convenience. General documentation requirements are also required
and found in the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook.
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10. Prior Authorization Requests Information for requesting prior authorizations specific to eye and vision services is presented in the subsections below. Requirements specific to a service or item are listed throughout the
handbook for the provider’s convenience. General information about prior authorizations may be found in the General Billing Instructions, Idaho Medicaid Provider Handbook. Incomplete
or incorrectly filled out prior authorization requests will be denied for improper documentation by NVA or the Medical Care Unit.
Prior Authorization Requests: Medical Care Unit The Medical Care Unit reviews requests for vision exams that exceed limitations. The required
request form is available on the Medical Care Vision Services webpage. Completed request forms should be e-mailed to [email protected] or faxed to 1 (877) 314-8779.
Requests must be faxed individually for HIPAA compliance. Incomplete requests will be denied.
The status of a prior authorization request for may be checked by providers online at the
Gainwell Technologies portal under “Authorization Status”, using your NPI. If there are questions regarding a denial, click on the notes, which will explain the reason for the denial.
Prior Authorization Requests: NVA National Vision Administrators (NVA) reviews prior authorization requests for glasses and
contact lenses. Prior authorizations, or prior approvals, are valid beginning the date they are received by NVA and are valid for two (2) months from the date of authorization. The required
request forms are available by logging into NVA’s website (www.e-nva.com). Requests should be submitted on NVA’s website or faxed to 1 (888) 483-6830. Requests must be faxed
individually for HIPAA compliance. Incomplete requests will be denied.
Requests may also be mailed to:
National Vison Administrators, L.L.C.
Attn: Idaho Medicaid Prior Approvals 1200 Route 46 West
Clifton, NJ 07013
Providers can view the outcome of the review by logging into their account at www.e-nva.com, or calling 1 (877) 626-2969.
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11. Reimbursement Providers must be enrolled to receive reimbursement from Idaho Medicaid. Idaho Medicaid reimburses medically necessary eye and vision services on a fee-for-service basis. Usual and
customary fees are paid up to the Medicaid maximum allowance listed in the Numerical Fee Schedule. Rates are set at 90% of the Medicare fee schedule when the code becomes covered
by Idaho Medicaid. Some participants may be responsible for a co-pay for services. NVA will bill Medicaid for any vision supplies.
See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding policy on
billing, prior authorization, and requirements for billing all other third-party resources before
submitting claims to Medicaid.
Participants who desire additional features non-covered by Medicaid may pay for them separately. The Medicaid contractor will bill the provider separately, and the provider may bill
their usual and customary charge to the participant. If the participant cannot adapt to new lenses that were not originally covered by Medicaid, the participant is responsible for any
additional charges. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for information on when billing a participant is allowable including
co-pays.
References: Reimbursement
11.1.1. Federal Regulations “Definitions.” Social Security Act, Sec. 1905(a)(5) (1935). Social Security Administration, https://www.ssa.gov/OP_Home/ssact/title19/1905.htm.
“Definitions.” Social Security Act, Sec. 1905(r)(2) (1935). Social Security Administration,
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House Bill 260 Budget Reductions – Provider Payments, Information Release MA11-19
(5/26/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-19.pdf.
House Bill 260 Budget Reductions – Vision Services, Information Release MA11-11
(5/24/2011). Division of Medicaid, Department of Health and Welfare, State of Idaho, https://healthandwelfare.idaho.gov/Portals/0/Providers/Medicaid/MA11-11.pdf.
11.1.3. Idaho State Plan “Reimbursement – General.” Enhanced Alternative Benefit Plan. Division of Medicaid,
Attachment 4.19-B. Department of Health and Welfare, State of Idaho.
11.1.4. State Regulations “Payment Availability.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,” Sec. 554. Office of
the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
Provider Payment, Idaho Code 56-265 (2020). Idaho State Legislature, https://legislature.idaho.gov/statutesrules/idstat/title56/t56ch2/sect56-265/.
“Vision Services: Provider Reimbursement.” IDAPA 16.03.09, “Medicaid Basic Plan Benefits,”
Sec. 785. Office of the Administrative Rules Coordinator, Division of Financial Management, State of Idaho, https://adminrules.idaho.gov/rules/current/16/160309.pdf.
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Medicare Crossovers for Vision Services No prior authorization is necessary for Medicare recipients of covered services. The provider may supply products from any lab they choose and bill Medicare. If National Vision
Administrators (NVA) is used, NVA will bill Medicare for the provider. In both cases, the claim will automatically crossover to Medicaid, which will pay the co-insurance/deductible. Normally
Medicare allows more than Medicaid due to contract prices, so no additional payment may be made. For more information on third party recovery or third party liability, see the General
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Third Party Insurance Billing Medicaid is the payer of last resort. If a Medicaid participant has other insurance for vision services, then the other insurance must be billed prior to billing Medicaid. Idaho Medicaid
does not require an explanation of benefits to be submitted for vision supplies ordered from Medicaid’s vision products contractor. NVA will deliver the requested supplies and bill the
third-party insurance. For more information on third party recovery or third party liability, see the General Billing Instructions, Idaho Medicaid Provider Handbook.
If the other insurance company requires an alternate provider of vision hardware, the participant must choose between the Medicaid product and the non-Medicaid product.
Medicaid will not provide reimbursement for the non-Medicaid product. See the General Information and Requirements for Providers, Idaho Medicaid Provider Handbook for
information on when billing a participant is allowable.