OHCA Policies and Rules

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317:30-5-10. Ophthalmology services

[Revised 02-01-08]

(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.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.