Ala. Admin. Code r. 560-X-17-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-17-.03 - Optometrist Services

(1) Services That May be Provided Other Than Correction of Refractive Error.

(a) In the conduct of an optometric eye examination, if the optometrist suspects or detects abnormalities or irregularities requiring medical treatment the case will be referred to an appropriate doctor of medicine or osteopathy.

(b) If medically necessary, contact lenses (for keratoconus, aphakia, high magnification difference between lenses), may be provided when prior authorized by Medicaid.

(c) Orthoptics (eye exercises) must be prior authorized by Medicaid. Full information justifying medical necessity (including number of sessions anticipated) must be sent in writing to Medicaid before this service is begun.

(d) Eyeglass lens changes, within lens specifications authorized by Medicaid, may be supplied when needed because of visual changes due to eye disease, surgery, or injury.

(e) Photochromatic lenses and UV400 coating may be prior authorized when justified in writing.

(f) Post-operative cataract patients may be referred by the ophthalmologist, with the patient's consent, to an optometrist for follow-up care as permitted by state law. Any subsequent abnormal or unusual conditions diagnosed during follow-up care shall be referred back to the ophthalmologist. When submitting claims the appropriate modifier identifying post-operative management must be utilized. If the ophthalmologist receives payment for the global amount the post-operative claim will deny. No post-operative management claim will be processed until referring ophthalmologist has received payment for surgery. It shall be the responsibility of the optometrist to confer with the ophthalmologist for appropriate claim corrections and/or submissions.

(2) Examination for Refractive Error Only.

(a) A complete eye examination and work-up is required and will include the following: case history, eye health examination, visual acuity testing, visual fields (if indicated), tonometry, prescribing eyeglasses (if indicated), and determining optical characteristics of lenses (refraction).

(b) For children, examination of eye tension and visual fields should be performed only if indicated.

(c) Medicaid recipients twenty-one (21) years of age and older are authorized one (1) complete eye examination and work-up every two (2) calendar years; recipients under twenty-one (21) years of age are authorized two (2) complete eye examinations and work-ups every calendar year or more often if medical necessity is documented.

(d) Diagnosis will be indicated as refractive error findings.

(e) Services rendered to Medicaid recipients while confined to bed in a health care facility may be rendered as long as it is documented by the patient's assigned physician that the patient is unable to leave the facility and the examination is medically necessary.

(3) If eyeglasses are required and provided, services will include verification of prescription, dispensing of eyeglasses (including laboratory selection), frame selection, procurement of eyeglasses, and fitting and adjusting of eyeglasses to the patient.

Ala. Admin. Code r. 560-X-17-.03

Rule effective October 1, 1982. Amended: effective June 8, 1985. Emergency rule effective December 1, 1986. Amended: Effective March 12, 1987; March 13, 1993. Emergency Rule effective April 15, 1993. Amended: Effective May 11, 1993. Amended: Filed July 7, 1994; effective August 12, 1994. Amended: Filed January 17, 2012; effective February 21, 2012. Amended: Filed July 12, 2012; effective August 16, 2012.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 09, June 30, 2021, eff. 8/14/2021.

Author: Elizabeth Huckabee, Program Manager; Physician and EPSDT Unit

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. § 435.520(3), 441.30(a)(b); State Plan, Attachment 3.1-A, pages 2.2, 5.1.