Oregon Administrative Rules
Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS
Division 140 - VISUAL SERVICES
Section 410-140-0260 - Contractor Services for Provider Ordering Vision Materials and Supplies

Universal Citation: OR Admin Rules 410-140-0260

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

(1) The Division contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to buy vision materials and supplies, excluding contact lenses. All frames, lenses, and miscellaneous items must be provided:

(a) Only by the contractor, unless the member has primary Medicare coverage; or

(b) By any visual materials supplier when the member has primary Medicare coverage for a Medicare covered item.

(2) Provider's shall:

(a) Verify the member's eligibility prior to submitting vision materials order to contractor;

(b) Obtain PA from the Division for items requiring PA prior to placing a vision materials order;

(c) Comply with the contractor's order submission requirements, as outlined in the Visual Services Supplemental Information Guide found at Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;

(d) Submit prescription or order to the contractor upon notification of PA approval from the contractor; and

(e) Pay SWEEP Optical for any services provided by SWEEP Optical to a member who is not eligible for items. SWEEP Optical may not sell materials and supplies for non-eligible members at the State Contracted Price.

(3) The Division covers glasses for:

(a) Eligible adults (age 21 and older) once every 24 months;

(b) Members once within 120 days following cataract surgery. When ordering glasses from contractor, the date of surgery must be listed on the order form;

(c) Eligible children (birth through age 20) without limitation when it is documented in the physician's or optometrist's clinical record as medically appropriate.

(4) The contractor shall:

(a) Forward Division PA approval to the provider;

(b) Order specifications:
(A) The contractor shall provide the order as specified by the ordering provider;

(B) The contractor shall pay for all shipping and handling charges for shipments to the provider via United States mail or United Parcel Service for all returned orders that do not meet the order specifications or that are damaged in shipping;

(C) The contractor may not accept initial orders via telephone. The contractor shall accept telephone calls or faxed messages regarding orders that do not meet specifications;

(D) When the contractor is notified of an item to be returned because the item was not made to specifications in the original order, the contractor shall begin remaking the product as soon as they are notified, whether or not they have received the item being returned. The ordering provider shall return the original product to the contractor with a written explanation of the problem and indicate the date they notified the contractor to remake the order;

(c) Original order delivery:
(A) The contractor shall deliver the original order of materials and supplies to the provider within ten business days of the date the order is received;

(B) In the event of a delay in manufacturing or delivery, the contractor shall:
(i) Notify the ordering provider within two business days of receipt of the order;

(ii) Include a description of the order, the reason for delay, and the revised time of completion and delivery.

(C) Delivery of special order frames and lenses may exceed the required delivery time. In this event, the contractor shall provide the ordering provider with notice of the anticipated delay, provide a projected delivery date, and document the actual delivery time.

(5) The contractor:

(a) May use the date of order as the date of service (DOS) but may not bill the Division until the order has been completed and shipped;

(b) Shall bill the Division using Health Care Common Procedure Coding System (HCPC) Codes listed in the contract agreement. Payment will be at contracted rates;

(c) Shall include eyeglass cases with every frame. Cases may not be included in orders for only lenses, temples, or frame fronts;

(d) Shall have unisex frame styles available and shall allow members to choose any frame regardless of category listed;

(e) Is not responsible if the Division determines the documentation in the member's record does not allow for the service pursuant to limitations indicated set forth in the administrative rules.

(6) The contractor and the Division may not pay for costs, expenses, or any required rework due to errors by the provider.

(7) Frames for display purposes may be purchased from the contractor for the same price as frames for glasses negotiated by the Oregon Department of Administrative Services:

(a) A case may not be provided with display frames; and

(b) Quantity, style, size, and color of frames should be specified in the order for display frames.

(8) Buying-up, as defined in OAR 410-120-0000 is prohibited.

(9) The following ophthalmic materials are not covered and include, but are not limited to:

(a) Glasses with a prescription that is equal to or less than +/-.25 diopters in both eyes;

(b) Two pair of glasses instead of bifocals or trifocals in a single frame;

(c) Hand-held, low vision aids;

(d) Non-spectacle mounted aids;

(e) Single lens spectacle mounted low vision aids;

(f) Telescopic and other compound lens systems, including distance vision telescopic, near vision telescopes, and compound microscopic lens systems;

(g) Extra or spare pairs of glasses;

(h) Anti-reflective lens coating;

(i) U-V lens;

(j) Progressive and blended lenses;

(k) Bifocals and trifocals segments over 28mm including executive;

(l) Aniseikonic lenses;

(m) Sunglasses; and

(n) Frame styles outside of the contract between the Division and contractor based on member preference and are not medically necessary.

(10) Costs for the following are included in reimbursement for the lens and are not separately reimbursed by the Division:

(a) Scratch coating;

(b) Prism;

(c) Special base curve; and

(d) Tracings.

(11) Materials that require PA are set forth in OAR 410-140-0040.

(12) If a frame cannot be located in the contractor's catalog at www.sweepoptical.com that meets the medical needs of the member:

(a) Providers shall contact contractor for assistance with locating a frame to meet the member's need; and

(b) Frames not included in the contract between the Division and contractor may be purchased through contractor with PA.

(13) The following services do not require PA, are subject to strict limitations, and require the physician or optometrist to submit appropriate documentation to contractor:

(a) Replacement parts for non-contracted frame styles are limited to frames purchased with PA approval;

(b) Tints and photochromic lenses are limited to members with documented albinism and pupillary defects. Documentation provided to contractor shall include the most appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code selected by a physician or optometrist;

(c) Other medically necessary items for a contract frame, when a member has a medical condition that requires the use of a specialty temple, nose pieces, head strap frame;

(d) Nonprescription glasses are limited to members that do not require any correction in one eye and where there is blindness in one eye. The purpose of this exception is to offer maximum protection for the remaining functional eye;

(e) High Index Lenses:
(A) Power is +/- 10 or greater in any meridian in either eye; or

(B) Prism diopters are 10 or more diopters in either lens;

(f) Polycarbonate lenses are limited to the following populations:
(A) Eligible children (birth through age 20);

(B) Members with developmental disabilities; and

(C) Members who are blind in one eye and need protection for the other eye, regardless of whether a vision correction is required.

(14) Regardless of verification received via phone or electronic sources, the contractor may not fill orders for members who do not have coverage or have met their vision benefit. When glasses are ordered and the member has met their vision benefit for the time period:

(a) The Division shall reimburse the provider for the exam only if the member is not an established member of the provider and the member is currently a fee-for-service (FFS) member with vision benefits;

(b) The provider shall contact the member's PHP or CCO if the member is enrolled with a PHP or CCO that contracts with SWEEP Optical. The contractor shall apply vision limitations pursuant to Division rules, regardless of changes to a member's enrollment status. The provider shall contact the member's PHP or CCO with the last date of service. The PHP or CCO shall determine if they will allow for an additional supply of glasses. If the member is an established member, regardless of incomplete information through phone or electronic verification systems or SWEEP Optical, the provider shall inform the PHP or CCO of the last date of service

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: ORS 279A.140, 414.025 & 414.065

Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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