Or. Admin. Code § 410-140-0200 - Glasses
(1) The Division
covers the fitting of glasses and the refitting and repair of glasses only when
glasses and replacement parts are purchased from:
(a) The Division's contractor;
(b) Any visual materials supplier when the
member has primary Medicare coverage or Third Party Liability (TPL) coverage
and the glasses were a Medicare-covered or TPL-covered benefit.
(2) The Division covers glasses
for:
(a) Eligible adults (age 21 and older)
once (1) 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.
(3) Fitting of glasses for:
(a) Eligible adults (age 21 years and older)
is limited to once (1) every 24 months, except when dispensing glasses within
120 days of cataract surgery;
(b)
Eligible children (birth through age 20) only when documented in the member's
record as medically necessary and medically appropriate.
(4) Periodic adjustment of frames and
tightening of screws is included in the dispensing fee and is not separately
reimbursed.
(5) The Division
accepts either the date of order or date of dispensing as the date of service
on claims. Glasses must be dispensed prior to billing the Division, except
under the following conditions:
(a) Death of
the member prior to dispensing; or
(b) Member failure to pick up ordered
glasses. Documentation in the member's record must show that the provider made
serious efforts to contact the member.
(6) Providers must keep a copy of the
delivery invoice included with all parts orders in the member's records or
document the delivery invoice number in the member's records for all repair and
refitting claims.
(7) Fitting of
spectacle mounted low vision aids, single element systems, telescopic or other
compound lens systems are not covered.
(8) All frames have a limited warranty. Check
specific frame styles for time limits. All defective frames must be returned to
the contractor.
(9) It is the
provider's responsibility to verify member eligibility and benefit coverage
pursuant to OAR 410-120-1140, prior to
submitting a visual materials order to SWEEP optical.
(10) If a member receives services under
section (2)(b) of this rule:
(a) The Division
may require a Prior Authorization (PA) for certain covered services or items
before the service may be provided and before payment is made; and
(b) Providers needing materials and supplies
are required to order those directly from SWEEP Optical, except when the OHP
member has primary Medicare coverage or Third Party Liability (TPL) coverage
(Refer to OAR 410-120-0000).
(11) 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 must be specified in the order for display
frames.
(12) 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.
(13) 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.
(14) Provider Error: Neither the contractor
nor the Division shall be responsible for costs, expenses or for any required
rework due to errors by any provider.
Notes
Tables referenced are not included in rule text. Click here for PDF copy of table(s).
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
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