Alliance Health routine eye exams Prior Auth

Coverage Criteria

EPSDT-covered services for beneficiaries under 21

Covered when EPSDT criteria are met and provider documents medical necessity to correct or ameliorate a defect, illness, or condition.

EPSDT medical necessity: Provider documents that the requested service, product, or procedure is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition identified through screening (EPSDT).meets EPSDT criteria

EPSDT may override normal policy limits when documentation supports medical necessity.

General eligibility and provider responsibilities

Coverage requires beneficiary enrollment and provider verification of eligibility.

Eligibility and verification: Beneficiary must be enrolled in NC Medicaid and the provider must verify eligibility at each service encounter.enrolled and verified

Some eligibility categories (e.g., Family Planning Waiver Program/MAFD) are not eligible for routine eye exams and visual aids.

General Criteria Covered

Covered when ALL of the following are met:

General coverage criteria: (a) The procedure, product, or service is individualized, specific, and consistent with symptoms or a confirmed diagnosis and not in excess of the beneficiary's needs; (b) it can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide; and (c) it is not primarily for the convenience of the beneficiary, caretaker, or provider.

These criteria support coverage determinations per Section 3.1.

Optical Services Covered

Specific optical services covered when provided by ophthalmologists and optometrists:

Specific covered services: (a) Routine eye exams with determination of refractive errors; (b) prescribing corrective lenses; and (c) fitting and dispensing approved visual aids. Opticians may fit and dispense approved visual aids only.

See Section 5.0 for service requirements, limitations, and provider roles.

EPSDT Exception Criteria

EPSDT exception allows exceeding policy limits for beneficiaries under 21 when medically necessary:

EPSDT exception: Provider documentation must demonstrate the requested service is medically necessary to correct, ameliorate, improve, or maintain the beneficiary's health, compensate for a health problem, prevent worsening, or prevent development of additional health problems per 42 U.S.C. §1396d(r).

Prior approval requirements still apply when specified; EPSDT does not cover services that are unsafe, ineffective, or experimental.

Routine Exam Components

Routine eye exam coverage and billing

Routine exam components included: Refraction, tonometry, biomicroscopy, depth perception, color vision, and ophthalmoscope study are included in the routine eye exam and must not be billed separately.

Visual acuity and tonometry findings must be kept in the beneficiary's health record though not required on the claim.

Early Exam/Refraction

Early exam/refraction prior approval criteria

Early exam/refraction PA: Prior approval is required for any early routine eye exam or refraction only performed within the one-year time limitation period.

The electronic PA must include documentation of medical necessity (e.g., significant decrease in acuity, medication effects, failed DMV screening) and corrected visual acuities (OD, OS, OU) or explanation for missing data; requests are reviewed case-by-case.

Visual Aids Supply and Limits

Visual aids (eyeglasses) coverage

Annual limit: Visual aids are limited to once every year; the one-year limit applies separately to frames and lenses and starts with the last approval date for each component.once per year per component

Early visual aids may be approved subject to criteria and prior approval.

Supplier: Medicaid eyeglasses are supplied by the DHHS optical laboratory contractor unless prior approval is granted for the provider to supply eyeglasses or components.

Provider-supplied exceptions require prior approval and invoice documentation.

Frames

Frame selection and exceptions

Frame selection and fitting kit: Beneficiaries must choose a frame from the Medicaid frame selection; providers must maintain a Medicaid fitting kit and shall not fit frames from a catalog or picture.

Approved frame list and fitting kit instructions available from the DHHS optical laboratory contractor.

Non-Medicaid frame exceptions: Requests for reimbursement for non-Medicaid frames are considered case-by-case and must include medical necessity documentation and detailed frame information (manufacturer, style, size, wholesale cost) on the electronic PA request.

If a beneficiary elects to purchase a non-covered frame privately, NC Medicaid will not pay for that frame or lenses and providers shall not bill Medicaid for beneficiary-purchased eyeglasses.

Use of beneficiary's own Medicaid frame: Use of the beneficiary's existing Medicaid frame (not new) may be approved when medical necessity is documented (e.g., significant prescription change or immediate post-surgical change); the frame must be identified on the PA request by manufacturer, style, and size.

Providers shall not mail the beneficiary's frame to NC Medicaid or contractors; contractor is not responsible for beneficiary-owned frames.

Lenses and Tints

Lens coverage criteria

Spectacle lens thresholds: Single vision lenses are covered when prescription is +/-0.50 diopters or greater in one meridian for either eye; bifocals require add power >= +1.00 diopter; trifocals require medical necessity documentation.see text

Requests below thresholds are reviewed case-by-case with supporting medical documentation.

Exceptional lens materials: Polycarbonate may be approved for single vision or bifocal prescriptions of +/-5.00 diopters or higher (or specific populations such as children birth through 6 years, blind/legally blind in one eye, or frequent trauma); Hi-Index may be approved at +/-5.00 diopters with distortion on polycarbonate or at +/-8.00 diopters or greater without medical documentation as noted.+/-5.00 diopters (or +/-8.00 for certain Hi-Index cases)

Medical necessity must be documented on the electronic PA where required.

Tints:

Uncut Lenses and Replacements

Uncut lenses and replacement visual aids

Uncut lenses for provider edging: Prior approval may be granted for uncut lenses from the DHHS optical laboratory contractor for provider edging; the provider must inspect lenses before edging and return flawed lenses to the lab at no charge; the provider assumes responsibility for edging errors.

The approved frame must be identified on the PA request by manufacturer, style, size, and color.

Replacement visual aids PA: Prior approval is required for replacement visual aids that are not covered under the manufacturer warranty; the electronic PA request must include appropriate documentation of the cause (police/accident/fire/FEMA/DSS/medical documentation as applicable) and evaluation of damage.

Prior approval requests missing evaluation information are returned for completion.

Covered with criteria

Covered when ALL of the following are met or appropriately documented and prior approval is obtained where required:

Submit electronic PA with supporting documentation: Electronic prior approval request submitted via NCTracks with supporting documentation appropriate to the request (police/accident/fire/FEMA/DSS/medical documentation when applicable).

Providers must include required clinical data (visual acuities OD/OS/OU, lens circumference when available) and invoice/manufacturer pricing where required.

Tint coverage: Specific tints (Pink #1/#2, Gray #1/#2/#3) or UV filter may be approved for documented photophobia diagnoses; other tints require medical justification.

PA must include medical necessity documentation.

Replacement for loss/damage/theft: Replacement of lost, stolen, or damaged visual aids considered case-by-case and requires documentation matching the cause (police report, accident report, fire report, FEMA/Red Cross documentation, medical documentation, or DSS/social worker letter). Providers must evaluate and document cause and extent; improper care or negligence do not constitute extenuating circumstances.

Coverage with documentation and billing rules

Covered when billed with appropriate documentation and prior approvals where required:

General coverage and billing requirements: Routine eye exams (S0620, S0621, 92015) and medically necessary visual aids (listed HCPCS/CPT codes) are covered when billed with documentation of medical necessity and dispense documentation; dispensing fees must not be billed until final dispensing is complete and contact lens claims must include manufacturer's invoice and be billed with dispensing codes on same claim.

Dispensing fees are paid only for approved Medicaid visual aids and must be billed by the dispensing provider after items are dispensed.

Routine Eye Exam Coverage

Covered services and limits

Routine eye exam coverage and limits: Routine eye exams and refractions are covered; prior approval is not required if no paid routine eye exam/refraction claim exists within the previous year as verified via the Web Tool, but providers should obtain a Web Tool confirmation on the day of service. New patient routine exams (S0620) are limited to once every three years for the same beneficiary and same provider.no prior paid claim within 1 year; S0620 once every 3 years per beneficiary per provider

If Web Tool shows a prior paid exam within one year, prior approval is required to avoid denial.

Visual Aids and Dispensing Criteria

Visual aids, eyeglasses, and contact lens coverage and billing requirements

Visual aids billing and dispensing rules: Prior approval is required for eyeglasses; dispensing fees must only be billed after the visual aids are dispensed and must be billed by the dispensing provider. Physician services cannot be billed on the same claim as visual aids. For provider-supplied eyeglasses, materials are billed at invoice cost with invoices attached and billed under V2799; contact lens claims must include manufacturer's invoice and the contact lens and dispensing codes must be billed together on the same claim.dispense before billing dispensing fee

Providers must use the same provider name/number on PA requests and claims; repairs/replacements must report actual authorization or dispensing date.

Warranty Frame Replacement Procedures

Replacement of frames covered under warranty is governed by the following operational steps and conditions

Warranty replacement process: Contact the DHHS optical laboratory contractor with frame information and a description of the problem; lab staff will check replacement frame availability. Defective frames under the one-year manufacturer warranty are covered; prior approval is not required for warranty replacements.one-year warranty from original approval date

Manufacturing defects are covered; abuse and neglect are not covered under warranty and abused frames must not be sent to the contractor.

Expedited handling when beneficiary lacks usable eyeglasses: Notify the DHHS optical laboratory contractor if the defective frame is not wearable and the beneficiary cannot function without eyeglasses and has no backup eyeglasses to enable expedited handling.

Enables lab to check availability and act accordingly.

Abuse/neglect handling: Do not send frames showing abuse or neglect to the DHHS optical laboratory contractor; seek prior approval for replacement. If the contractor receives a damaged frame showing abuse/neglect, it will be returned to the provider or forwarded to NC Medicaid for evaluation and follow-up.

Beneficiaries enrolled in the Family Planning Waiver Program (MAFD) who have Family Planning Waiver benefits are not eligible for routine eye examinations or visual aids under this policy.

The following specific items and services are not covered: affixing or engraving initials or name on frames or lenses; anti-reflective coatings; tinted or cosmetic contact lenses; contact lens supplies (except the initial care kit when issued with approved contact lenses); gradient tints, sunglasses, or any tint not medically justified by diagnosis; over-the-counter hand-held magnifiers or visual aids purchasable without a prescription; non-ophthalmic frames (sunglasses, wrap-around, cosmetic, etc.); progressive or blended multifocals; repairs under $5.00; rimless frames requiring grooving/drilling/faceting/beveling; safety glasses; scratch resistant coating; sport straps/chains; photochromatic lenses; and hand-held low-vision magnifiers. Providers must inform beneficiaries before purchase that Medicaid will not pay for these non-covered services and must arrange payment directly with the beneficiary.

Routine eye exam components — including refraction, tonometry, biomicroscopy, depth perception, color vision, and ophthalmoscope study — are part of the routine eye examination and must not be billed separately. Visual acuity and tonometry findings must be retained in the beneficiary's health record even though they are not required on the claim.

If a beneficiary elects to purchase a non-Medicaid frame privately, NC Medicaid will not pay for that frame or for lenses purchased as part of that private transaction. Providers shall not bill NC Medicaid for eyeglasses purchased directly by the beneficiary.

Replacement requests due to loss, theft, accident, fire, natural disaster, or medical condition are reviewed case-by-case and require supporting documentation. Improper care or negligence does not qualify as an extenuating circumstance for replacement approvals and therefore is not a valid basis for an approved replacement.

Providers shall not request the DHHS optical laboratory contractor to provide materials or services that are prohibited by the contractor's agreement with NC Medicaid. The contractor is not authorized to bill providers for non-covered services, and corrections for contractor errors are not billed to NC Medicaid or the provider; such errors are to be prioritized for expediting replacements.

Providers shall follow applicable modifier guidelines but must not bill modifiers for services covered under the Routine Eye Examination and Visual Aids policy.

General ophthalmological office visits and consultations are components of the routine eye exam and must not be billed separately by the same provider on the same day as a routine eye exam (S0620 or S0621) or a refraction only (92015), except when separate medical necessity is documented.

Manufacturer warranties cover manufacturing defects for frames. Abuse or neglect are not covered under the warranty; do not send abused frames to the DHHS optical laboratory contractor. Instead, seek prior approval for replacement. If the contractor receives a frame that shows evidence of abuse or neglect, it will be returned to the provider or forwarded to NC Medicaid for evaluation and follow-up.

Services are not covered when the beneficiary does not meet eligibility requirements (Section 2.0), does not meet policy criteria (Section 3.0), the service duplicates another provider's service, or is experimental/investigational/part of a clinical trial. Requests for single vision prescriptions of less than +/- 0.50 diopters are not covered unless accompanied by documentation of medical necessity. Additionally, procedures billed without justification and documentation of medical necessity are subject to recoupment.

Single vision spectacle lenses are covered only when the prescription is + or - 0.50 diopters or greater in one meridian (sphere, cylinder, combination, or prism) for either eye. Requests for prescriptions less than +/- 0.50 diopters require supporting documentation of medical necessity and are evaluated on a case-by-case basis.

Procedures billed without supporting documentation of medical necessity and without justification in the beneficiary's health record are subject to recoupment. Ensure medical necessity is documented and retained in the record when submitting claims for services or visual aids.

Coding and Billing

CPT/HCPCS/ICD-10/Modifiers referenced in attachmentsmixed

No codes listed

Routine Eye Exam and Refraction OnlyHCPCS | CPTCovered

S0620	Routine ophthalmological examination including refraction; new patient
S0621	Routine ophthalmological examination including refraction; established patient
92015	Determination of refractive state (refraction only)

Visual Aids MiscellaneousHCPCSCovered

V2799

Vision services, miscellaneous (frames, lenses, special services), Provider's Supply of Medicaid Frames/Lenses (Requires Justification and Prior Approval)

Visual Aids and Dispensing CodesCPT | HCPCSCovered

92340	Fitting of spectacles, except for aphakia; monofocal (single vision lens - 1)
92341	Fitting of spectacles, except for aphakia; bifocal (bifocal lens - 1)
92342	Fitting of spectacles, except for aphakia; multifocal other than bifocal (trifocal lens - 1)
92353	Fitting of spectacle prosthesis for aphakia; multifocal (cataract lens - 1)
92370	Repair and refitting spectacles, except for aphakia (dispense frame)
V2600	Handheld, low vision aids
V2615	Telescopic and other compound lens systems
V2610	Single lens spectacle mounted low vision aids
V2797	Supply of low vision aids (dispense low vision aid)
V2510	Contact lens, gas permeable, sph, per lens

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Refractive and Eye Diagnosis ICD-10-CM examplesICD-10

H44.21
H44.22
H44.23
H52.01
H52.02
H52.03
H52.11
H52.12
H52.13
H52.211

Routine exam and refraction codes (covered)HCPCS | CPTCovered

S0620	New patient routine eye exam
S0621	Routine eye exam (referenced alongside S0620)
92015	Refraction only

Visual aids miscellaneous codes (covered)HCPCSCovered

V2799	Vision services, miscellaneous (used when materials billed at invoice cost for eyeglasses)
V2599	Initial contact lens care kit

inv-36: Lens diopter thresholds

Single-vision lens coverage thresholdSingle vision lenses must be +/−0.50 diopters or greater in one meridian to be covered; prescriptions below +/-0.50D are evaluated case-by-case with medical justification.

Bifocal add power thresholdBifocals require an add power of +1.00 diopter or greater.

Exceptional lens material thresholdsPolycarbonate or hi‑index lenses considered for single vision or bifocal prescriptions of +/-5.00 diopters or higher; hi‑index also covered at +/-8.00 diopters or higher without medical necessity documentation.

Trifocal requirementTrifocals require documentation of medical necessity (e.g., Rx warrants intermediate correction or previous wearer).

Provider Actions, Prior Approval & Documentation

Prior Authorization

Prior Authorization Required

Medicaid requires prior approval for certain eye care services and visual aids. Providers must submit electronic prior authorization (PA) requests via the Web at http://www.nctracks.nc.gov (or contact the Optical Services Program for urgent needs at 919-527-7669). Prior approval is required for: any early routine eye exam or refraction requested within the one‑year limitation; all visual aids (except frame warranty replacements); provider‑supplied eyeglasses, lenses, or frames when an exception is requested; replacement visual aids not covered by manufacturer warranty; medically necessary contact lenses and certain extended‑wear or disposable lenses when documentation or cost justification is required; and miscellaneous vision services billed with V2799. Providers must attach all supporting documentation and clinical records to the PA request so the DHHS Utilization Review Contractor can evaluate medical necessity.

Prior approval required for early exams/refraction within one year (case‑by‑case review).
Prior approval required for all visual aids except frame warranty replacements.
Prior approval required for provider‑supplied eyeglasses/lenses/frames when requesting an exception.
Prior approval required for non‑warranty replacements (lost, stolen, damaged) with supporting documentation.
Prior approval required for medically necessary contact lenses; prior approval may be granted for extended/frequent/disposable lenses with medical justification or cost parity evidence.

Background

A routine eye examination assesses eye health and visual acuity in the absence of disease or symptoms and includes determination of refractive errors, refraction, and prescribing corrective lenses. It is intended to evaluate organ health and functional vision in beneficiaries who do not present with acute ocular disease.

Definitions

inv-76: Routine eye examination definition

DefinitionAn examination of the eyes in the absence of disease or symptoms to determine organ health and visual acuity; includes refraction and prescribing corrective lenses.

Included servicesRoutine eye exam includes determination of refractive errors, refraction, and components such as tonometry, biomicroscopy, depth perception, color vision, and ophthalmoscope study (these components must not be billed separately).

ProvidersPerformed by ophthalmologists, optometrists, and opticians within their NC scope of practice.

inv-77: Visual aids definition

DefinitionManual correction of diminished eyesight by lenses (ophthalmic eyeglass frames and lenses and medically necessary contact lenses) supplied under Medicaid.

Components and limits

Revision History

1976-02-01original_effective_date

Policy originally became effective (Original Effective Date).

2011-10-01revision

Policy promulgated for recipients under 21 years of age; all sections and attachments revised as initial promulgation under HB 200 changes.

2012-07-15revision

All sections and attachments revised to align with prior Clinical Coverage Policy 6A and related statutory updates.

OpenPayer

Routine Eye Examination and Visual Aids for Beneficiaries Under 21 Years of Age