N.J. Admin. Code § 10:62-2.5 - Optical appliances and related services requiring prior authorization

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Form MC-9(A) (Request for Authorization and Payment--Optical Appliances) shall be used for requesting prior authorization for optical appliances. Instructions for completing the form are provided in the Fiscal Agent Billing Supplement. The completed form clearly indicating the reasons for requesting the appliance requiring prior authorization must be submitted to the Vision Care Unit, Division of Medical Assistance and Health Services, Mail Code #16, PO Box 712, Trenton, New Jersey 08625-0712. When a request for authorization is approved or denied, the provider shall receive a letter of notification from the fiscal agent.
(b) Items requiring prior authorization should not be provided to the Medicaid or NJ FamilyCare fee-for-service beneficiary until the authorization is received by the provider. (See N.J.A.C. 10:49-6 ).
(c) Authorization becomes invalid upon termination of eligibility for the New Jersey Medicaid/NJ FamilyCare fee-for-service programs, except when the termination occurs between the time the optical appliance is ordered and the time the optical appliance is dispensed. (Note: The provider shall use the date the optical appliance is ordered as the date of service when this situation occurs.)
(d) The following optical appliances require prior authorization:
1. Low vision devices when the total charge to the Medicaid or NJ FamilyCare fee-for-service program is $ 150.00 or more;
2. Vision training devices;
3. Repair of an optical appliance when the charge to the Medicaid or NJ FamilyCare fee-for-service program is $ 15.00 or more;
4. Replacement of optical appliances;
i. In circumstances not covered in N.J.A.C. 10:62-2.4, the replacement of an optical appliance requires prior authorization. For example: If lost, broken and irreparable, stolen or a prescription change is less than 0.50 diopter or five degrees in axis.
5. Dual pairs of glasses instead of multifocal;
6. Optical tints;
7. High index lenses;
8. Special base curve;
9. Artificial eye if provided more frequently than once every three years;
10. Intraocular lenses implantations if for more than two implantation procedures per beneficiary per lifetime;
11. Replacement of a contact lens within two years;
12. Protective prescription eyewear; and
13. All other optical appliance items requiring additional charges or not identified in N.J.A.C. 10:62-3.4.
(e) Optical appliance services rendered to New Jersey Medicaid/NJ FamilyCare fee-for-service beneficiaries who are enrolled in an MCO that includes these services in its benefits package must be prior authorized by the MCO/primary care provider. The Fiscal Agent Billing Supplement contains details regarding obtaining prior authorization.


N.J. Admin. Code § 10:62-2.5
Amended by 49 N.J.R. 2279(b), effective 7/17/2017

The following state regulations pages link to this page.

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.