Okla. Admin. Code § 317:30-5-10

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-10 - Ophthalmology services

(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.

Okla. Admin. Code § 317:30-5-10

Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 17 Ok Reg 3354, eff 8-1-00 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2134, eff 6-27-02; Amended at 24 Ok Reg 2824, eff 5-1-07 (emergency); Amended at 25 Ok Reg 653, eff 2-1-08 through 7-14-08 (emergency)¹; Amended at 25 Ok Reg 2634, eff 7-25-08

¹This emergency action expired on 7-14-08 before being superseded by a permanent action. Upon expiration of an emergency amendatory action, the last effective permanent text is reinstated. Therefore, on 7-15-08 (after the 7-14-08 expiration of the emergency action), the text of 317:30-5-10 reverted back to the permanent text that became effective 6-27-02, as was last published in the 2006 Edition of the OAC, and remained as such until amended again by permanent action on 7-25-08.