Medicaid Billing for Materials

[Mindyme57]

Hey all -

I am considering trying to expand our Medicaid coverage from exam only to DME (Durable Medical Equipment... aka glasses and contact lenses). It's been a few years since I worked at an office that billed for specifically routine exam and eyeglasses. I think I have a handle on the glasses (bill for poly, aspheric, dispensing fee/adjustments, keep all on single HICF, inexpensive frame, patient pays for other upgrades-photochromic/AR, only bill for 1 pair per day). But while I was reviewing CPT codes and I am seeing decent payments for Exam (92004/92014) and believe it or not a CL Exam code (92310) for over $100.00 per my states payment schedule. I also see payment schedule for the contact lenses too (V2520 / V2521).

I would like to pick the brain of anyone currently taking and filing claims for glasses and Ideally Contact Lenses. I want to know if it does work without need any prior approval or any other hoops we need to jump through without causing too much brain damage.

If I am incorrect on my understand of billing glasses, or missed something important please let me know as well!

Thank you all!

[Excel-Lentes]

Hi,

Each state administers its own medicaid program. You would need to consult with the CO medicaid program directly for those details. From what I read some states use Eyemed and some use the prison system to fabricate eyewear and the optician receives a small dispensing fee. Where I live contacts are medically necessary only. The reimbursement is not sustainable for the contacts materials. We currently process all the eyewear and select which frames to offer so we can largely control costs, quality and service.

~Peace and health

[Mindyme57]

Thank you for the response! For my state Colorado, they don't have it run by any 3rd party for eyeglass fabrication.
I've heard contact lenses are medically necessary but I was reviewing the fee schedule they don't have any asterisk or indication of that on their list. For the contacts the only way I could see it working is if you put the patient into a daily disposable and bill per box. Order them 1 month at a time type of thing.

Side question if you know it, when billing on a HICF to Medicaid, does it all need to be on 1 form? I've heard it can be a nightmare trying to have them pay on a 2 page HICF.

Thanks again!

[Excel-Lentes]

I have not heard of standard contact lenses covered under a Medicaid program. As far as the forms; are you talking about paper claims? My state program has its own secure website for billing. Seems paper claims would be impractical in 2022!

[Mindyme57]

Paper Claims such dinosaurs! But yes, that's how my former office filed claims for glasses so I assumed that is the only way to do so, this was over 4 years ago. But that would be lovely if there is an online portal. Thank you for you sharing your knowledge. I'll let you know if I find out any good bits.

[Excel-Lentes]

A quick look found this;

https://hcpf.colorado.gov/vision-benefit

If that is the CO Medicaid program, only medically necessary CL and only children can get routine eyewear.