C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-75, subsec. 144-101-II-75.04

Current through 2024-51, December 18, 2024

Subsection 144-101-II-75.04 - VISION SERVICE PROVIDER REQUIREMENTS

75.04-1Chapter I Requirements

Vision service providers must comply with all provisions of Chapter I, Section 1, General Administrative Policies and Procedures, of the MaineCare Benefits Manual.

75.04-2Vision Care Volume Purchase Contractor

A.Sole Supplier

Vision service providers must use MaineCare's designated Vision Care Volume Purchase Contractor (the Contractor) as the sole supplier of all eyeglasses for MaineCare members with no Medicare or other third party coverage, except as noted in Section 75.04-4(D). This includes lenses, frames, associated parts and cases.

For those contract services/articles that require prior authorization, the provider must request prior authorization from the MaineCare Prior Authorization Unit or its authorized agent before placing an order with the Contractor. If the request is approved, the MaineCare Authorization Unit or its authorized agent will send written notification to both the provider and the Contractor.

The Contractor will not fill any provider orders without receiving notice of approval and a prior authorization number from the MaineCare Authorization Unit or its authorized agent.

If a MaineCare member has coverage for eyeglasses from Medicare or any other third party, the provider must follow his/her customary practice for the acquisition of these items rather than the above rules relating to acquisition from the Contractor. If these items are to be covered by MaineCare only, however, then they must be acquired in accordance with the above rules relating to acquisitions from the Contractor.

B.Vision Care Volume Purchase Warranty

1. The Contractor must warrantee all articles purchased under the Vision Care Volume Purchase Contract for a minimum of one (1) year after delivery to the member. This warranty need not cover patient abuse or damage from normal wear and tear.

If the dispensing provider finds any article supplied under the contract to be unsatisfactory due to defective materials or workmanship, the provider may return the article to the Contractor and the Contractor will correct, adjust or replace the defective article at the Contractor's expense for a period of up to one year after delivery to the member. Such defects or errors may include but are not limited to:

a. Lenses that are broken, scratched, or chipped at the time of receipt by the provider; or

b. Lenses that deviate from the provider's prescriptions beyond the deviation standards permitted by the ANSI Z80 Committee on Ophthalmic Standards.

The provider must return such articles to the Contractor. The Contractor must mail corrected or replacement articles to the provider within seven (7) working days of receipt of the unsatisfactory materials.

2. The provider must honor and enforce any express manufacturer warranties in excess of one (1) year.

C.Responsibility for Materials Lost in Transit

The sender (either the Contractor or the provider) must replace materials lost in transit, at no charge to MaineCare or the MaineCare member. The Contractor is responsible for furnishing postage-paid mailers to MaineCare providers for use in returning defective materials to the Contractor. The Contractor is solely responsible for the cost of materials lost in transit when the provider uses the Contractor's postage-paid mailers to return defective materials. The provider is responsible for the cost of replacing the materials lost in transit when the provider does not use Contractor postage-paid mailers to return defective materials.

75.04-3Professional Consultation - Ophthalmologists and Optometrists

A. When an ophthalmologist or optometrist detects signs of a treatable disease, he/she may arrange a medical consultation between an appropriate physician or specialist and the MaineCare member. MaineCare will reimburse the consulted professional for his/her consulting services.

MaineCare members participating in managed care need a referral from their primary care provider for any consultations as required by the managed care rules published in the MaineCare Benefits Manual, Chapter VI, Section 1, Primary Care Case Management.

B. The referring ophthalmologist or optometrist is not permitted to receive compensation from MaineCare or from the consultant for setting up the consultation.

C. When a consultation has been arranged, any invoice submitted by the ophthalmologist or optometrist or the consultant must indicate that a consulting relationship has been established.

75.04-4Procedure to Request Prior Authorization

Vision service providers must submit a written request for prior authorization to the MaineCare Authorization Unit or its authorized agent for certain services/articles described in this Section. The Vision Care Volume Purchase Contractor will not fill any orders for those contract services/articles that do require prior authorization without approval and a prior authorization number from the MaineCare Authorization Unit or its authorized agent.

In addition to the provisions described in the MaineCare Benefits Manual, Chapter I, Section 1, General Administrative Policies and Procedures, regarding prior authorization, providers must comply also with the requirements described below.

For all requests, providers must include the member's name, ID number, and birth date.

A. For contact lenses, low vision aids, or eyeglasses for members under age twenty-one (21) when the refractive error does not meet the criteria in 75.03-2(B)(2), providers must supply:

1. Pertinent history;

2. Visual acuity with and without correction;

3. Refractive error;

4. Status of fusion;

5. Keratometric readings for contact lens (es);

6. Diagnoses; and

7. Specific plan of treatment, including materials specifications for contact lenses or low vision aids.

B. For orthoptic therapy services, providers must supply:

1. Diagnoses;

2. Reasons for recommended orthoptic therapy and expected results;

3. Visual acuity with and without correction;

4. Status of fusion;

5. Refractive error;

6. Measurement of deviation at distance and/or near, with and without correction, and the method of measurement;

7. Specific plan of treatment;

8. Length of time the therapy is to be continued;

9. Possibility of arranging for device for training at home; and

10. Cost of the recommended therapy.

C. For frames and/or lenses that cost more than the MaineCare maximum allowance and/or for medically necessary frames and or lenses that cannot be provided by the Contractor, providers must supply clinical documentation indicating medical necessity, e. g., allergy to materials used by Contractor. MaineCare will reimburse providers at the wholesale cost, not to exceed $70.00/set of frames.

D. Providers must mail prior authorization requests to:

MaineCare Authorization Unit

MaineCare Services

Department of Human Services

11 State House Station

Augusta, Maine 04333-0011

E. The MaineCare Authorization Unit or its authorized agent will send written notification indicating approval or disapproval to the provider. The MaineCare Authorization Unit or its authorized agent will send approval and a prior authorization number to the Vision Care Volume Care Contractor if appropriate. If the request is approved, the provider must write the prior authorization number on the invoice.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-75, subsec. 144-101-II-75.04