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    v1.0.30
    OpenPayerPolicy UpdatesOphthalmology/OptometryLouisiana Medicaid Vision Coverage | OpenPayer
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    CurrentLouisiana Department of HealthPolicy 12-11

    Vision Services for Bayou Health Members

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    This policy governs coverage, prior authorization, claims submission, and care coordination for routine eye exams and eyewear for Louisiana Medicaid members enrolled in Bayou Health health plans or legacy Medicaid. Bayou Health plans must provide vision services at least at the legacy Medicaid amount, duration, and scope, while plan-specific requirements may vary.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyVision Services for Bayou Health Members
    Policy CodePolicy 12-11
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionFollow the applicable health plan or legacy Medicaid prior authorization requirements for eyewear and other vision services when prior authorization is indicated.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Under age 21Legacy Medicaid routine eye exam eligibility
    1 per yearLegacy Medicaid routine eye exam limit
    5Bayou Health vision subcontractors
    Medically necessaryCovered eyewear requirement

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    Vision Service Coverage

    Legacy Medicaid Routine Eye Exams

    Covered routine eye exams under the legacy Medicaid Program require ALL of the following:

    ALL of the following

    • The member is enrolled in the legacy Medicaid Program and is under age 21.
    • The routine eye exam is limited to one reimbursable exam per calendar year.1 per calendar year

    Eyewear Medical Necessity

    Eyewear services are reimbursable only when medically necessary.

    The covered eyewear service is medically necessary.

    Bayou Health Plan Coverage

    Bayou Health plans must provide vision services, including eye exams and eyewear, at least at the same amount, duration, and scope as legacy Medicaid.

    ALL of the following

    • The member is enrolled in a Bayou Health plan: Aetna, Amerigroup, AmeriHealth Caritas, Louisiana Healthcare Connections, or UnitedHealthcare.
    • The plan provides vision services, including eye exams and eyewear, in at least the same amount, duration, and scope as legacy Medicaid.
    • Routine vision services do not require a referral.
    • Any plan-specific prior authorization limits or requirements are satisfied when applicable; plans may establish requirements that differ from legacy Medicaid. Refer to the applicable plan provider handbook.
    • Vision-service coordination and prior authorization questions are directed to the plan's vision subcontractor: Aetna—Block Vision, 1-800-879-6901; Amerigroup—Block Vision, 1-800-787-3157; AmeriHealth Caritas—Vision Service Plan (VSP), 1-800-877-7195; Louisiana Healthcare Connections—OptiCare, 1-888-898-9880; UnitedHealthcare—March Vision, 1-866-675-1607.

    Covered eyewear services that are not medically necessary are not reimbursable.

    Authorization and Documentation Requirements

    Prior Authorization

    Bayou Health Prior Authorization Requirements

    Bayou Health plans must provide vision services, including eye exams and eyewear, at least to the same amount, duration, and scope as legacy Medicaid. However, each plan may establish prior authorization limits and requirements that differ from legacy Medicaid; review the applicable provider handbook and contact the plan’s vision subcontractor for current requirements. Routine vision services do not require a referral.

    • Applicable plans include Aetna, Amerigroup, AmeriHealth Caritas, Louisiana Healthcare Connections, and UnitedHealthcare.
    • Aetna: Block Vision, 1-800-879-6901; Amerigroup: Block Vision, 1-800-787-3157; AmeriHealth Caritas: Vision Service Plan (VSP), 1-800-877-7195.
    • Louisiana Healthcare Connections: OptiCare, 1-888-898-9880; UnitedHealthcare: March Vision, 1-866-675-1607.
    Prior Authorization

    Legacy Medicaid Eyewear Authorization

    For members enrolled in legacy Medicaid, follow the legacy Medicaid fee-for-service policy and requirements for eyewear, including applicable prior authorization procedures.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyVision Services for Bayou Health Members
    Policy CodePolicy 12-11
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionFollow the applicable health plan or legacy Medicaid prior authorization requirements for eyewear and other vision services when prior authorization is indicated.
    SourceLink
    On This Page
    Vision Service CoverageAuthorization and Documentation Requirements
    • When prior authorization is indicated, obtain it from the Molina Prior Authorization Unit at 1-800-488-6334, through ePA at www.lamedicaid.com, or by fax at 225-929-6803.
    Documentation Required

    Document Medical Necessity

    Document the facts supporting the medical necessity of all covered eyewear services. Adequate medical-necessity documentation is required for reimbursement.

    • Maintain supporting documentation in accordance with the applicable Bayou Health plan or legacy Medicaid requirements.
    Billing Rule

    Age, Frequency, and Medical Necessity Limits

    For legacy Medicaid members, routine eye exams are covered for enrollees under age 21 and are limited to one exam per calendar year. Covered eyewear services must be medically necessary to qualify for reimbursement.

    • Age limit: under 21.
    • Frequency limit: one routine eye exam per calendar year.
    • Eyewear must be medically necessary.
    Denial Risk

    Follow the Applicable Authorization Process

    Providers must follow the prior authorization requirements applicable to the member’s coverage. Failure to comply with the Bayou Health plan’s requirements or the legacy Medicaid fee-for-service requirements may result in noncompliance and jeopardize reimbursement for eyewear and other vision services.

    • For Bayou Health members, verify requirements with the member’s health plan, provider handbook, and vision subcontractor.
    • For legacy Medicaid members, use the Molina prior authorization process when authorization is indicated.