Oregon Administrative Rules
Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS
Division 140 - VISUAL SERVICES
Section 410-140-0050 - Eligibility and Benefit Coverage

Universal Citation: OR Admin Rules 410-140-0050

Current through Register Vol. 63, No. 9, September 1, 2024

(1) Providers shall verify that an individual is an OHP member and eligible for benefits prior to providing services to ensure reimbursement for services provided. If the provider fails to confirm eligibility on the date of service, the provider may not be reimbursed. Providers must verify the member's eligibility including:

(a) That the member receiving vision services is eligible on the date of service for the service provided;

(b) Whether an OHP member receives services on a fee-for-service basis or is enrolled with a PHP or CCO;

(c) That the service is covered under the member's OHP Benefit Package; and

(d) Whether the service is covered by a third party resource (TPR).

(2) The Division OHP vision benefit packages:

(a) For non-pregnant adults (age 21 and older):
(A) Visual services and materials to diagnose and correct disorders of refraction and accommodation are covered only when the member has a covered medical diagnosis, following cataract surgery or a corneal lens transplant as described in OAR 410-140-0140, or when the member is in their protected post-partum 12-month period (see OAR 410-200-0135);

(B) Orthoptic and pleoptic training (vision therapy) is not covered; and

(C) Other visual services are covered with limitations as described in this rule.

(b) For pregnant adult women (age 21 and older):
(A) Orthoptic and pleoptic training (vision therapy) is not covered; and

(B) Other visual services are covered with limitations as described in these rules;

(c) For children (birth through age 20): Visual services are covered as described in this rule and without limitation when documentation in the clinical record justifies the medical need.

(3) Providers shall maintain accurate and complete member records, which includes documenting the quantity of services provided, as outlined in OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records). For comprehensive eye exams, the standard of care and expectation is that the provider shall provide a dilated exam and document the type of dilating drops and time of dilation.

(4) The provider shall inform an OHP member when:

(a) Vision service or materials are not covered under the member benefit package;

(b) Service limitation has been met and the benefit is no longer covered.

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 414.025 & 414.065

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