N.Y. Comp. Codes R. & Regs. tit. 18 § 537.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 537.4 - Reimbursement for payments to dispensing opticians and other retail optical establishments

(a) The maximum reimbursable allowance for services of dispensing opticians and other retail optical establishments (including salaried optometrists employed by retail optical establishments) shall be as follows:

FEES FOR LENSES AND FRAMES

First or single pair of eyeglasses

Code	Item	Fee	Remarks2
E601	Single vision, standard chart thickness	**	1
E651	hardening and testing *	$2.22
E661	tinting	**	prior approval
E701	Single vision, over-standard chart thickness	**	prior approval
E751	hardening and testing *	$3.70	prior approval
E761	tinting	**	prior approval
E801	Bifocals	**
E851	hardening and testing *	$4.00
E861	tinting	**	prior approval
E901	Trifocals	**
E951	hardening and testing *	$4.44
E961	tinting	**	prior approval
E521	Frame, wholesale cost up to $4.00	**
E621	Frame, wholesale cost more than $4.00	**	prior approval

¹ Prior approval required if correction is less than 1/2 diopter.

^* Hardening, testing and markup (48%) included in this fee.

^** Reimbursement at actual wholesale cost to the dispenser plus 48 percent above such cost. The following amounts will be accepted as minimum wholesale costs in computing the markup.

Single vision lenses and frames $5.50...............................

Bifocal lenses and frames 8.00.....................................................

Trifocal lenses and frames 13.00..........................................................

² Remarks applicable only in the medical assistance program.

Second pair of eyeglasses (dispensed at same time)

Code	Item	Fee	Remarks2
E602	Single vision, standard chart thickness	**
E652	hardening and testing *	$2.22
E662	tinting	**	prior approval
E702	Single vision, overstandard chart thickness	**	prior approval
E752	hardening and testing *	$3.70	prior approval
E762	tinting	**	prior approval
E522	Frame, wholesale cost up to $4.00	**
E622	Frame, wholesale cost more than $4.00	**	prior approval
FEES FOR OTHER SERVICES
E500	Examination by a salaried optometrist 3 to include diagnosis for optical deficiency and for visual or musclar anomaly of the human eye	$5.004
E503	Contact lenses-provided for ocular pathology only and recommended by an ophthalmologist	by report	prior approval
E571	Adjustment by other than original provider	$2.00
E581	Repair for replacement of broken parts (wholesale cost plus 60 percent markup over wholesale cost) minimum of	$2.00

^* Hardening, testing and markup (48%) included in this fee.

^** Reimbursement at actual wholesale cost to the dispenser plus 48 percent above such cost. The following amounts will be accepted as minimum wholesale costs in computing the markup.

Single vision lenses and frames $5.50

Bifocal lenses and frames 8.00....................

Trifocal lenses and frames 13.00.......................

² Remarks applicable only in the medical assistance program.

³ "Salaried optometrist" means a qualified optometrist employed by either a retail optical establishment or dispensing optician or a non-profit health service corporation as defined in article IX-C of the State Insurance Law.

⁴ The eye examination provided by a qualified salaried optometrist to be accepted as the basis for prescription of eyeglasses shall include, as a minimum, the components of an optometric examination contained in section 505.6 of the Title. Eye examinations which do not meet this standard will not be considered acceptable for purposes of payment from funds under public tax-supported medical care programs. Payment of this fee is effective August 1, 1975.

(b) The fees provided herein (including markup) are intended to cover all services performed by the above providers in connection with the dispensing of eyeglasses and will be considered full payment for services rendered under State-administered programs. Under the medical assistance program, which is administered by local social services districts, these fees (including markup) represent a maximum allowance for purposes of State reimbursement.

(c) Need for two pairs of eyeglasses, one pair for distance and one for near vision, should be uncommon. Such dispensing must be substantiated by the patient's particular needs, such as proven inability to tolerate bifocals, the unusual nature of the patient's correction, physical ailments, and other conditions which make provision of bifocals inadvisable. Two pairs of eyeglasses should not be provided merely as an alternative to bifocals to satisfy an unjustificable preference on the part of the patient, for personal convenience or for cosmetic purposes.

(d) The following standards shall be observed in providing lenses and frames.

(1) In all claims for payment, the model or style, name, catalog number and name of manufacturer of the lenses and frames supplied must be included.

(2) All lenses, frames and frame parts shall be guaranteed against defects in manufacture or assembly.

(3) Billing may be based on wholesale prescription assembled cost, regardless of origin of finished services.

(4) All claims for payment are subject to audit which must include verification of wholesale costs.

(5) Only first quality frames shall be supplied. The dispenser shall be responsible for any needed replacement or repairs that are due to defects in quality or material or workmanship.

(6) Frames provided shall not exceed a wholesale cost of four dollars except, that for clinical reasons documented by the prescribing ophthalmologist or optometrist, a more expensive frame may be approved for an individual. Such exceptions require prior approval by the appropriate medical director and prior authorization by the social services commissioner.

(7) No extra charge shall be made by a dispenser of eyeglasses for future fittings and adjustments if he has dispensed the eyeglasses. Provision for this service has been included in the above fee.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 537.4