Library: Policy

317:30-5-431. Coverage by category

Revised 2-1-08

     Payment is made to optometrists as set forth in this Section.

• (1) Adults.  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.

  • (A)  There is no provision for routine eye exams, examinations for the purpose of prescribing glasses or visual aids, determination of refractive state, 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.  Prior to providing non-covered services, providers must notify members in writing of those services not covered by SoonerCare.  Determination of refractive state or other non-covered services may be billed to the patient if properly notified.

  • (B) 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 surgeon's information must be in the referring provider's section of the claim.

  • (C) Payment for laser surgery to optometrist is limited to those optometrists certified by the Board of Optometry as eligible to perform laser surgery.

• (2) Children.  Eye examinations are covered when medically necessary.  Determination of the refractive state is covered when medically necessary.

• (3) Individuals eligible for Part B of Medicare.  Payment is made utilizing the Medicaid allowable for comparable services.