Vision Coverage Guidelines

Medical Coverage Guidelines

Click here to see the Provider Reference Manual.

Provider Participation Guidelines

To participate in the Medicaid Program, providers must be located and performing services in Rhode Island or in a border community. 

Consideration will be given to out-of-state providers if the covered service is not available in Rhode Island, the recipient is currently residing in another state or if the covered service was performed as an emergency service while the recipient was traveling through another state.

Provider Enrollment

Providers who wish to enroll with RI Medicaid, should view the instructions in the General Guidelines Reference Manual. 

Recertification

Optometrists are annually recertified by the Rhode Island Department of Health (RIDOH). The license expiration date for Optometrists is January 31. Providers obtain license renewal through RIDOH. Out of state providers must forward a copy of the renewal documentation to Gainwell Technologies. Gainwell Technologies should receive this information at least five business days prior to the expiration date of the license. Failure to do so will result in suspension from the program. Opticians are recertified by the RIDOH every two years. A provider may appeal to the RIDOH if they do not meet the recertification criteria. If the appeal to RIDOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS).

Reimbursement Guidelines

The reimbursement rates for Optometric services are listed in the Fee Schedule. Providers must bill the Medicaid Program at the same usual and customary rate as charged to the general public and not at the published fee schedule rate. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to the Medicaid Program. Payments to providers will not exceed the maximum reimbursement rate of the Medicaid Program.

Claims Billing Guidelines

Optometric services are billed on the CMS 1500 claim form. Instructions for completing the CMS 1500 claim form are located in Claims Processing.

Modifiers

Modifiers must be used when billing for lenses or contact lenses.

  • TC modifier    —    Technical component
  • RT modifier    —    Right eye
  • LT modifier    —    Left eye
  • 26 modifier    —    Professional component
  • 50 modifier     —    Bilateral procedure
  • 51 modifier    —    Multiple procedures
  • 52 modifier     —    Reduced services (use if billing for one eye only)

Medicare/Medicaid Crossover

The Medicaid Program reimbursement for crossover claims is always capped by the established Medicaid Program allowed amount, regardless of coinsurance or deductible amounts. The standard calculation for crossover payments is as follows: 

The Medicaid Program will pay the lesser of: 

  • The difference between the Medicaid Program allowed amount and the Medicare Payment (Medicaid Program allowed minus Medicare paid); or
  • The Medicare coinsurance and deductible up to the Medicaid Program allowed amount, calculated as follows: (Medicare coinsurance/deductible plus Medicare paid) – (Medicaid Program allowed)

Crossover Eyeglass Claims Requiring EOMB

Medicare/Medicaid crossover claims for eyeglasses containing diagnosis code V43.1, 379.31 or 743.35 must have the Medicare EOMB attached when submitted to The Medicaid Program for payment. If the EOMB is not attached, the claim will be returned to the provider. This policy is effective for claims with dates of service on or after October 1, 1993. Claims not containing one or more of the above diagnosis codes do not require attachment of the EOMB form.

Patient Liability

Medicaid Program reimbursement is considered payment in full. The provider is not permitted to seek further payment from the recipient in excess of the Medicaid Program rate. A provider shall not bill Medicaid for eyeglass frames and receive payment from the member for the difference in cost.

Covered/Non Covered Services

Overview

Effective August 16, 1993, a limitation was placed on Optometric Services covered by the Medicaid Program to recipients age 21 and older. The following services are covered for these recipients: 

  • One (1) refractive eye care examination 
  • One (1) pair of eyeglasses (lenses, frames and dispensing fee) 
  • One (1) pair of contact lenses 

Claims for the above services provided after August 16, 1993 will not be paid when such services have been provided to the recipient within the previous twenty-four (24) month period. Medically necessary office visits for diagnosis and treatment of illness or injury of the eye will continue to be provided. Providers should use standard Evaluation and Management procedure codes for office visits related to diagnosis and treatment of illness or injury of the eye. Exam procedure codes should not be used. 

 

The Medicaid Program does not pay for:

  •  a spare pair of eyeglasses • information provided over the telephone 
  • canceled office visits or appointments not kept 
  •  lost or stolen frames or lenses

Optometric Procedure Codes

These procedure codes can be viewed in the manual on pages 9-31. 

Replacement items

Frames or lenses for recipients age 21 and older are not covered.

EPSDT

The limitations described above do not apply to recipients under the age of 21, to whom the Medicaid Program gives special consideration under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.   

Contact Lenses

Contact lenses require prior authorization and will be covered when such lenses provide better management of a visual or ocular condition than can be achieved with spectacle lenses, as well as for Unilateral Aphakia, Keratoconus, Corneal Transplant, and High Anisometropia. This determination will be done through the prior authorization process.

Two procedure codes should be used when billing for contact lenses; fitting/dispensing codes and actual lens code.

Trifocals

Trifocals will be covered only when the patient has a special need due to job training program or extenuating circumstances.

Oversized Lenses/Deluxe Frames

Oversized lenses and deluxe frames will be covered only when deemed medically necessary, but not for cosmetic reasons.

Polycarbonate Lenses

Lenses will be covered for patients under 21 when it is considered medically necessary. Lenses will also be covered for patients over 21 for the following diagnoses: H54.40 - H54.42A5.

Tints

Tints or UV lenses are covered when the tints or UV lenses are necessary due to one of the following diagnoses: Other disturbances of aromatic amino-acid metabolism, Degeneration of macula and posterior pole, Cataracts, Keratitis, Corneal opacity and other disorders of cornea, Disorders of conjunctiva, Aphakia, Aniridia, and Pseudophakos and deemed medically necessary by the prescribing provider. The provider must indicate the diagnosis code on the written prescription and that a tint is medically necessary.

Initial Refraction Exams

Payment will not be made for an initial refraction exam if a medical encounter visit was performed on the same date of service.

Special Requirements

Payment for any prior authorized services can only be made if the services are provided while the person remains eligible for the Rhode Island Medicaid Program.

Unlisted Procedures

Providers who perform an unlisted procedure code must obtain prior authorization for the service before submitting the claim for payment. Medical justification for the procedure must be included with the request for authorization.