Optician services are recognized in Kentucky Medicaid as Provider Type (52) individual or (529) group and may bill Kentucky Medicaid using these provider type codes. To provide services to a Medicaid beneficiary, any optician or optician group must be:
- licensed in the state in which where located
- enrolled with Kentucky Medicaid and
- enrolled with the managed care organization (MCO) of any beneficiary it treats.
Covered Services
If determined medically necessary, opticians help people choose and fit eyeglasses frames and contact lenses. They follow prescriptions from optometrists or ophthalmologists. Professional dispensing services, lenses, frames and repairs are covered for persons younger than 21.
KY Medicaid reimburses for no more than one pair of eyeglasses per beneficiary per the calendar year unless:
- the eyeglasses are broken or lost during the calendar year or
- eyeglass prescription changes during the calendar year.
If an event occurs within the calendar year, Kentucky Medicaid reimburses for one additional pair of eyeglasses during the calendar year. A prism, if medically necessary, is included in the cost of lenses.
Contact lenses are covered under 907 KAR 1:632 Section 5(1).
Safety glasses require documented proof of medical necessity.
Verifying eligibility
Once eligibility is obtained, verify continued eligibility by one of the following methods:
- contact the automated voice response System at (800) 807-1301
- use the web-basedKYHealth-Net System
Optometrists must meet the coverage provisions and requirements of907 KAR 1:632 to provide covered services. All services must be performed within the scope of practice for any provider. Providers must follow Kentucky Medicaid regulations and the requirements of the MCO in which they participate. All services must be medically necessary.
Non-Covered Services
Procedures not considered medically necessary are not covered by Kentucky Medicaid. For example, Kentucky Medicaid does not reimburse for telephone consultation; press-on prism or service with a CPT code or item with an HCPCS code not listed on the Department for Medicaid Services Vision Program Fee Schedule
Reimbursement
Reimbursement for optician services is in accordance with the Behavioral Health Fee Schedule and defined in
907 KAR 1:631.
Duplication of Service
Kentucky Medicaid does not reimburse for a service provided by more than one provider of any program in which the service is covered during the same period.
Prior Authorization
Fee-for-service beneficiaries who require prior authorization for additional services deemed medically necessary, contact
CareWise. MCO beneficiaries who require prior authorization for medically necessary additional services, contact your MCO for more information.
Claims Submission
Kentucky Medicaid currently contracts with
Gainwell Technologies to process fee-for-service claims. Each MCO processes its own claims.
Coding
Kentucky Medicaid uses the National Correct Coding Initiative edits as well as the McKesson Claim Check System to verify codes that are mutually exclusive or incidental. Kentucky Medicaid also uses Correct Procedural Terminology codes and Healthcare Common Procedure Coding system codes. Kentucky Medicaid requires the use of ICD-10 codes on all claims submitted for reimbursement. Kentucky Medicaid requires the use of CMS 1500 billing forms. Providers must bill Kentucky Medicaid using the correct CPT codes.
Claim Appeals
Appeal requests made on denied fee-for-service claims must be submitted to
Gainwell Technologies. The request must include the reason for the request along with a hard copy claim. Please refer to the MCO if appealing an MCO claim.
Timely Filing
Claims must be received within 12 months of the date of service or six months from the Medicare pay date, whichever is longer, or within 12 months of the last Kentucky Medicaid denial. Please refer to the MCO if appealing an MCO claim.
Provider Contact Information
Billing Questions -
Gainwell Technologies - (800) 807-1232
Provider Questions - (855) 824-5615
Provider Enrollment or Revalidation - (877) 838-5085
KyHealth.net assistance -
Gainwell Technologies - (800) 205-4696
Pharmacy Questions - (800) 432-7005
Pharmacy Clinical Support Questions - (800) 477-3071
Pharmacy Prior Authorization - (800) 477-3071
Physician Administered Drug List - Pharmacy Branch - (502) 564-6890
Provider MCO Information
Anthem - (800) 205-5870
Aetna Better Health of KY - (855) 300-5528
Humana - (855) 852-7005
Molina - (800) 578-0775
WellCare of KY - (877) 389-9457