Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 24 - VISUAL CARE SERVICES
Section 471-24-005 - BILLING AND PAYMENT FOR VISUAL CARE SERVICES
Universal Citation: 471 NE Admin Rules and Regs ch 24 ยง 005
Current through September 17, 2024
005.01 BILLING.
005.01(A)
GENERAL BILLING REQUIRMENTS. Providers must comply
with all applicable billing requirements codified in 471 NAC 3. In the event
that billing requirements in 471 NAC 3 conflict with billing requirements
outlined in this 471 NAC 24, the billing requirements in 471 NAC 24 will
govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
BILLING
REQUIRMENTS. Providers must bill Nebraska Medicaid for visual care
services on the appropriate claim form or electronic format.
005.01(B)(ii)
USUAL AND CUSTOMARY
CHARGE, The provider or their authorized agent must submit the
provider's usual and customary charge for services rendered. The provider's
total charge for services may not exceed the provider's usual and customary
charge.
005.01(B)(iii)
NON-COVERED SERVICES. If the provider furnishes items
or services not covered by Nebraska Medicaid, on a private basis, the
individual must pay the full charge of the items or services. The provider is
prohibited from billing Nebraska Medicaid for any portion of the non-covered
items or services.
005.01(B)(iv)
BILLING THE RECIPIENT FOR FRAMES. Charges for frames
purchased by a recipient on a private pay basis must include the associated
fitting charge.
005.01(B)(v)
BILLING FOR LENSES.
005.01(B)(v)(1)
SCRATCH RESISTANT
COATING. 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. Nebraska Medicaid does not require that lenses with scratch resistant
coating be warranted:
005.01(B)(v)(2)
BILLING THE
RECIPIENT.
005.01(B)(v)(2)(a)
LENSES. Charges for lens purchased by a recipient on a
private pay basis must include the associated fitting charge.
005.01(B)(v)(2)(b)
SPECIAL LENS
FEATURES AND LAB PROCEDURES- If non-covered lens features or lab
procedures other than non-covered tints are desired by recipients, they must be
purchased on a private pay basis.
005.01(B)(v)(2)(c)
LENS
TINTS. The recipient can be billed for non-covered lens tints
under the following conditions:
(i) The
recipient has been notified by the provider in writing that Nebraska Medicaid
will not cover the lens tint: and
(ii) The recipient voluntarily agrees to
reimburse the provider for the lens tint on a private pay basis.
005.02 PAYMENT.
005.02(A)
GENERAL PAYMENT
REQUIREMENTS. Nebraska Medicaid will reimburse the provider for
services rendered in accordance with the applicable payment regulations
codified in 471 NAC 3. In the event that payment regulations in 471 NAC 3
conflict with payment regulations outlined in 471 NAC 24, the payment
regulations in 471 NAC 24 will govern.
005.02(B)
SPECIFIC PAYMENT
REQUIRMENTS.
005.02(B)(i)
REIMBURSEMENT. Nebraska Medicaid pays for covered
visual care services in an amount equal to the lesser of:
(1) The provider's submitted charge:
and
(2) The allowable amount for
the procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect
for that date of service.
005.02(B)(ii)
MEDICARE AND
NEBRASKA MEDICAID CROSSOVER CLAIMS. For information on the payment
of Medicare and Nebraska Medicaid crossover claims, see 471 NAC. 3.
005.02(B)(iii)
COPAYMENT. For Nebraska Medicaid copayment
requirements, see 471 NAC 3.
005.02(B)(iv)
PAYMENTS FOR EYE
EXAMS. Eye examinations provided primarily for the purpose of
prescribing, fitting, or changing eyeglasses for refractive errors are
reimbursed at the Nebraska Medicaid fee schedule allowable for intermediate
level general ophthalmological services, as defined in the American Medical
Association's Physicians' Current Procedural Terminology (CPT). Determination
of the refractive state is reimbursed separately from examination
services.
005.02(B)(v)
PAYMENTS FOR VISION THERAPY TRAINING. Payment for
vision therapy training includes all equipment and supplies necessary for home
use.
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