This manual is designed to be used in conjunction with other sections of the Utah Medicaid Provider Manual, such as Section I: General Information of the Utah Medicaid Provider Manual (Section I: General Information) and the Physician Services Utah Medicaid Provider Manual.
The information in this manual represents available services when medically necessary. Services may be more limited or may be expanded if the proposed services are medically appropriate and are more cost effective than alternative services.
Vision care services are available for individuals eligible for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and pregnant women.
Eyeglass services, including lenses and frames, are available to pregnant women and those eligible under the EPSDT program. Non-pregnant adults age 21 and older are NOT covered for eyeglass services.
Optometry care services covered by the Utah Medicaid Program include the examination, evaluation, diagnosis and treatment of visual deficiency; removal of a foreign body; and prescription and provision of corrective lenses by providers qualified to perform the service(s).
This manual provides information regarding Medicaid policy and procedures for fee-for-service Medicaid members.
A Medicaid member enrolled in a Managed Care Plan (MCP) (health, behavioral health or dental plan) must receive services through that plan with some exceptions called “carve-out services,” which may be billed directly to Medicaid. An MCP may use this manual as a reference to find out what Medicaid covers.
Refer to the provider manual, Section I: General Information, for information regarding MCPs and how to verify if a Medicaid member is enrolled in an MCP. Medicaid members enrolled in MCPs are entitled to the same Medicaid benefits as fee-for-service members. However, plans may offer more benefits than the Medicaid scope of benefits explained in this section of the provider manual. Contact the Medicaid Member Services hotline at (844) 238-3091 for further information.
Medicaid does not process prior authorization requests for services to be provided to a Medicaid member enrolled in an MCP when the services are the responsibility of the plan. Providers requesting prior authorization for services for a member enrolled in an MCP will be referred to that plan.
Medicaid makes every effort to provide complete and accurate information regarding a member’s enrollment in a managed care plan. However, it is the provider’s responsibility to verify eligibility and plan enrollment for a member before providing services. Therefore, if a Medicaid member is enrolled in a MCP, a fee-for-service claim will not be paid unless the claim is for a “carve-out service.”
Eligibility and plan enrollment information for each member is available to providers from these sources:
Additional definitions of terms used in Medicaid programs are available in Section I: General Information of the Utah Medicaid Provider Manual (Section I: General Information). Definitions specific to the content of this manual are provided below.
Eyeglasses
Means lenses, including frames, contact lenses, and other aids to vision that are prescribed by a physician skilled in diseases of the eye or by an optometrist.
Ophthalmologist
A person specifically trained as a physician who specializes in anatomy, physiology, pathology, disorders and treatment of the eye. Ophthalmologists must be licensed to practice medicine in the state where the services are provided.
Optician
A person specifically trained to translate optical prescriptions, prepare lenses, and fit and dispense eyeglasses. Opticians are reimbursed as ‘optical suppliers’ who must be licensed by the appropriate governmental authority licensing businesses in the state where the services are provided.
Optometrist
A person specifically trained and licensed, in accordance with the Utah Optometry Practice Act and the State of Utah Administrative Rule, Optometry Practice Act Rule (r156-16a). Optometrists must be licensed in the state where the services are provided.
Providers must be enrolled as a Utah Medicaid provider to be reimbursed for services. Refer to provider manual, Section I: General Information for provider enrollment information.
A Medicaid member is required to present the Medicaid Member Card before each service, and every provider must verify each member’s eligibility each time before services are rendered. For more information regarding verifying eligibility, refer to provider manual, Section I: General Information, Verifying Medicaid Eligibility and to the Eligibility Lookup Tool located at https://medicaid.utah.gov/eligibility.
Procedure Codes
With some exceptions, procedure codes with accompanying criteria and limitations have been removed from the provider manual and are now found on the Medicaid website Coverage and Reimbursement Lookup Tool at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
The eye examination includes evaluation, diagnosis and treatment of visual deficiency and abnormalities of the eye and visual system. Examinations must be documented as medically necessary in the member record.
The examination fee includes the refraction (glasses prescription) and the office visit. Do not bill an office visit separately from the eye examination (See Chapter 6, Billing).
One routine eye examination per year is covered for Medicaid members with two exceptions.
Medical necessity is required for corrective lens coverage. Medical necessity includes a change in prescription or replacement due to normal lens wear. Corrective lenses must be suitable for indoor or outdoor, day or night use.
Lenses covered include single vision, bifocal, trifocal, with or without slab-off prism, in clear glass or plastic. If the prescription changes, the same frame must be used if possible (See Chapter 4-1.3, Frames).
Separate charges for glasses fitting are not reimbursable when the provider is supplying the frame and lenses. Fitting fees are included in the reimbursement rate for the provided items.
When medically necessary, Medicaid provides one standard frame, plastic or metal. Frames must be reusable and if the lens prescription changes, the same frame must be used when possible. Medicaid reimburses one pair of eyeglasses every 12-month period.
Medicaid will reimburse for repair or replacement of a damaged lens or frame.
Replacement eyeglasses are allowed for eligible members once every 12-month period. Prior authorization is required to replace frames sooner than 12 months; replacement lenses are covered and do not require prior authorization. If the lenses alone need replacing, the provider must use existing frames.
Prior authorization may be issued for a new pair of eyeglasses, even though 12 months have not passed since a member’s last pair was dispensed when one or more of the following reasons for medical necessity are met:
Contact lenses require written prior authorization. Refer to 6-1, Prior Authorization.
Contact lenses may be covered under the following circumstances:
Fitting contact lenses includes determining correction measurements, writing the prescription, fitting and follow-up care necessary for proper wear of the contact lens. Medicaid will not reimburse any additional office visits for any of these services.
Soft contact lenses may be approved when medically necessary because of a condition described in “A” above and for either circumstance below:
Gas permeable contact lenses may be approved when a specific medical need exists which precludes the use of glasses.
Contact lenses are not covered for moderate visual improvement and/or cosmetic purposes.
Medications may be prescribed to treat eye disease or injury. The treating optometrist must be certified under the Optometry Practice Act. Medications dispensed in an office are not reimbursable, they are part of the office visit.
Low vision aids or materials may be covered. These items require prior authorization and manual pricing. See Chapter 6-1, Prior Authorization.
Prostheses, such as an artificial eye, and associated services are covered when medically necessary.
With few exceptions, a provider may not bill a Medicaid member, as the Medicaid payment is considered payment in full. Exceptions may include a member request for service that is not medically necessary and therefore not covered. Examples of services considered not medically necessary: more expensive frames, tinted lenses, lenses of special design.
For a provider to bill the member the following conditions must be met. (See also Section I: General Information, Exceptions to Prohibition on Billing Members)
Unless all four conditions are met, the provider may not bill the member for the non-covered service. Further, the provider may not “hold” the member's Medicaid card as guarantee of payment, nor may any other restrictions be placed upon the member.
If providing upgraded services such as more expensive frames, tinted lenses, or lenses of special design, bill the covered code and charges on the first line. On the second line, bill the non-covered code, including the modifier “GX” (HCPCS “GX” modifier description: Notice of liability issued, voluntary under payer policy) and the charges on the second line. This indicates that the member has signed a memo of understanding of the payment responsibility for the upgrade(s). The code with the GX modifier will be non-payable. The memo of understanding must be kept in the provider’s medical record for the member.
The amount paid by the member is calculated by taking the difference between the usual and customary charge for the more expensive item and the usual and customary charge for the covered item. For example, if the usual and customary charge for the basic frame were $35 and the member wanted frames that were presently advertised for $50, the member would be responsible to pay an additional $15. Remember, because Medicaid pays $27.61 for the $35 basic frame, the provider accepts this as payment in full and cannot bill the member for the $7.39 difference.
For additional non-covered services or limitations, refer to the Coverage and Reimbursement Lookup Tool at the Medicaid website at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
The following services are NOT covered by Medicaid.
Vision care services may be billed electronically or on paper, using the CMS-1500 (08/05) claim format. Refer to the provider manual, Section I: General Information, for detailed billing instructions.
If a member chooses non-covered services or upgrades, refer to 4-1.11 Member chooses non-covered services or upgrades for billing information.
Prior authorization may be required for certain services. Failure to obtain prior authorization can result in payment denial by Medicaid. Providers must determine if prior authorization is necessary and obtain authorization before providing services. Exceptions may be made, with appropriate documentation, if the service provided is emergent or the member is retro-eligible for the dates of service requested.
Prior authorization (PA) information is provided in the provider manual, Section I: General Information. Code specific coverage and prior authorization requirements are provided on the Medicaid website, Coverage and Reimbursement Lookup Tool at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
When requesting prior authorization, complete the requirements found in Section I: General Information include documentation supporting the diagnosis.
Examples of information to include in the prior authorization request.
Updated April 2019