Current through Vol. 42, No. 1, September 16, 2024
(a)
Covered
services for adults.
(1) Payment can be
made for medical services that are reasonable and necessary for the diagnosis
and treatment of illness or injury up to the patient's maximum number of
allowed office visits per month.
(2) There is no provision for routine eye
exams, examinations for the purpose of prescribing glasses or visual aids,
determination of refractive state or treatment of refractive errors, or
purchase of lenses, frames, or visual aids. Payment is made for treatment of
medical or surgical conditions which affect the eyes. Providers must notify
members in writing of services not covered by SoonerCare prior to providing
those services. Determination of refractive state or other non-covered service
may be billed to the patient if properly notified.
(3) The global surgery fee allowance includes
preoperative evaluation and management services rendered the day before or the
day of surgery, the surgical procedure, and routine postoperative period.
Co-management for cataract surgery is filed using appropriate CPT codes,
modifiers and guidelines. If an optometrist has agreed to provide postoperative
care, the optometrist's information must be in the referring provider's section
of the claim.
(b)
Covered services for children.
(1) Eye examinations are covered when
medically necessary. Determination of the refractive state is covered when
medically necessary.
(2) Payment is
made for certain corrective lenses and optical supplies when medically
necessary. Refer to OAC
317:30-5-432.1.
for specific guidelines.
(c)
Individuals eligible for Part B of
Medicare. Payment is made utilizing the Medicaid allowable for
comparable services.
(d)
Procedure codes.
(1) The
appropriate procedure codes used for billing eye care services are found in the
Current Procedural Terminology (CPT) and HCPCS Coding Manuals.
(2) Vision screening is a component of all
eye exams performed by ophthalmologists or optometrists and is not billed
separately.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 17 Ok Reg 3354, eff 8-1-00 (emergency); Amended at 18 Ok
Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 24 Ok
Reg 2824, eff 5-1-07 (emergency); Amended at 25 Ok Reg 653, eff 2-1-08 through
7-14-08 (emergency)1; Amended at 25 Ok Reg 2634, eff
7-25-08
1This emergency action expired
on 7-14-08 before being superseded by a permanent action. Upon expiration of an
emergency amendatory action, the last effective permanent text is reinstated.
Therefore, on 7-15-08 (after the 7-14-08 expiration of the emergency action),
the text of 317:30-5-10 reverted back to the permanent text that became
effective 6-27-02, as was last published in the 2006 Edition of the OAC, and
remained as such until amended again by permanent action on
7-25-08.
