Vision

Preventive Eye Exams with Refraction

Nebraska Heritage Health Adult Program members

Members 20 and under: One complete eye exam every year; more frequent exams will be covered if medically necessary and appropriate to diagnose or treat a specific eye illness, symptom, complaint or injury.

Members 21 and older: One complete eye exam every two years; more frequent exams will be covered if medically necessary and appropriate to diagnose or treat a specific eye illness, symptom, complaint or injury.

• Members may be eligible for additional exams as indicated in the Nebraska Medical Assistance Program (NMAP) guidelines.
• Eligible diagnosis for preventive vision exams can be found on our website at Provider Forms (centenevision.com/forms). Navigate to Eligible International Classification of Disease (ICD)Coding Information and select Eligible ICD Codes for All Markets.
• Report refraction (92015) separately when billing the exam with a 92XXX code.
• Regardless of final diagnosis, a member who presents for a routine exam with no complaint must be reported as a preventive exam using a routine diagnosis code as the primary diagnosis. Additional diagnoses identified during the examination should be reported following the initial routine diagnosis that corresponds with the chief complaint.
• CPT II codes 2022F-2033F and 3072F are separately reimbursable when reported for evaluation of diabetic retinopathy. Submit 2022F-2033F for results corresponding to current year findings, or 3072F to report no retinopathy in the prior year.

Medical Services

Medically necessary eye care services as indicated in the member’s evidence of coverage, performed by an optometrist, and in compliance with applicable co-management policies, benefit limitations, and/or medical diagnosis are covered for all members.

Eyeglasses - Frames

One pair of frames every two years for members of all ages if:

• It is the member’s first pair of prescription eyeglasses.
• Size change needed due to growth.
• If there is a change in the prescribed lenses and the new lenses cannot be accommodated by the current frame.
• The current frame is no longer usable due to irreparable wear/damage, breakage, or loss.

Providers must prescribe new frames in compliance with the standards specified by the Nebraska Administration Code, Ch.24, § 004 Nebraska Rules and Regulations. Eligible diagnosis for routine optical services can be found at CenteneVision.com/forms. Navigate to Eligible ICD Coding Information and select Eligible ICD Codes for All Markets.

Eyeglasses - Lenses

One pair of lenses (glass or plastic) every two years for members of all ages if:

• It is the member’s first pair of prescription eyeglasses.
• Refraction is at least 0.50 diopters in any meridian.
• Size change needed due to growth.
• New lenses are required due to a new prescription when the refraction correction meets one of the following criteria. (A copy of the former and current prescriptions must be maintained in the provider's records.):
  • Change of 0.50 diopters in the meridian of greatest change when placed on an optical cross;
  • Change in axis in excess of 10 degrees for 0.50 cylinder, 5 degrees for 0.75 cylinder;
  • Change of prism correction of ½ prism diopter vertically or 2 prism diopters horizontally or more
• The current lens is no longer usable due to irreparable wear/damage, breakage, or loss.
• Providers must prescribe new lenses in compliance with the standards specified by  the Nebraska Administration Code, Ch.24, § 004.

Specifications for Lenses:

• All plastic lenses must include front surface scratch resistant coating (factory applied or "in-house" dipped). The cost for the scratch resistant coating must be included in the lens cost and is not billed under a separate procedure code. The laboratory invoice must indicate that the scratch resistant coating was provided. NMAP does not require that lenses with scratch-resistant coating be warranted;
• Lenses must be of a quality at least equal to Z-80 standards of the American National Standards Institute.
• Additional lens features are covered as outlined in the Nebraska Administration Code, Ch.24, § 004.

Additional Eyewear/Replacements

Additional Eyewear:

• Members 20 and under are eligible for additional frames and/or lenses more frequently if medically necessary and appropriate.
• Replacement modifiers are not required; however, documentation of medical necessity must be maintained in the member’s file.

Replacements:

• Members 21 and older are eligible for replacement eyewear (frames and/or lenses) once every 12 months when damage is irreparable due to wear/damage, breakage or loss or for prescription changes when the member’s condition meets the criteria outlined.
• Replacement Contact Lenses are covered due to loss, damage or for prescription changes. Benefits are available with accordance with Nebraska Administration Code, Ch.24, § 004. when the member's condition meets the criteria as outlined in the NMAP guidelines.  Replacements must be billed using either the RA or RB modifier.

Frame Repair

Frame repair is covered in the following circumstances:

• The cost of repairing the frame is less than providing a new frame.
• The repair would provide a serviceable frame for the member.

Applicable manufacturer warranties must be pursued for broken eyeglasses.

Post-cataract Eyewear

• Members who have undergone cataract surgery are entitled to one covered in full pair of standard frames and lenses or contact lenses when medically necessary. No prior authorization required.
• Claims for post-cataract eyeglasses should be submitted with diagnosis code Z96.1.
• This benefit is allowed once per eye, per lifetime.

Medically Necessary Contact Lenses

Prior authorization is not required for medically necessary eyewear; however, claims are subject to retrospective review. Please maintain documentation in the member’s file of the necessity of the eyewear and/or services provided.

Contact Lenses Including Fitting Fees:

• May be obtained in lieu of eyeglasses when medically necessary as outlined in the NMAP guidelines.
• Include a medical diagnosis when submitting claims.

Prosthetic Eyes

• Prosthetic eyes are covered as outlined in the NMAP Durable Medical Equipment (DME) guidelines.
• Replacement of medically necessary, Medicaid-covered DMEPOS owned by the client is covered if needed due to change in the client's medical condition, wear, loss, irreparable damage, except for malicious damage, culpable neglect or wrongful disposition.

Vision Therapy

• Covered when medically necessary.
• Limit of 22 sessions per member.
• All services are subject to retrospective review.

EPSDT

When applicable, providers should submit diagnoses that demonstrate medical necessity under our clinical policies or relevant clinical documentation with services they believe are medically necessary under applicable Early and Periodic Screening, Diagnostic, and Treatment requirements.

Member Billing

Providers may bill a plan member for non-covered service only when the member agrees in writing, in advance of the services being rendered. It is recommended that providers obtain and retain a signed Non-Covered Services Liability Acknowledgment form from the member indicating their agreement to pay for such services. A Non-Covered Service Liability Acknowledgement form is available at Provider Forms (centenevision.com/forms).