OAR 410-140-0410: Provider Responsibility

(1) The Oregon Health Authority (Authority) uses several approaches to promote program integrity and prevent fraud, waste and abuse in the Medicaid program (Refer to OAR 410-120-1395) (2) The Division enrolls the following as providers of vision services: (a) An individual licensed by the relevant state licensing authority to practice optometry; and (b) A licensed ophthalmologist; and (c) An optician as defined in ORS 683.510-683.530; (3) The provider must verify whether an MCE or the Division is responsible for reimbursement. (a) Providers shall comply with MCE policies, including PA requirements, for reimbursement. Providers shall inform MCEs of the last date of service when inquiring about service limitations. Failure to follow MCE rules may result in the denial of payment; and (b) If the provider has been denied payment for failure to follow the rules established by the MCE, neither the Division, the MCE, nor the MCE member are responsible for payment; and (c) If the MCE uses the Division’s visual materials contractor or another visual materials contractor for visual materials and supplies, all issues shall be resolved between the MCE and the contractor; and (d) Pursuant to OARs 410-120-1560 through 410-120-1700, the Provider may appeal a decision in which the provider is directly adversely affected. (4) Providers shall comply with the following rules in addition to the Visual Services program rules to determine service coverage and limitations for OHP members according to their benefit packages: (a) General Rules (OAR Chapter 410, Division 120); (b) OHP administrative rules (Chapter 410, Division 141); (c) Health Evidence Review Commission's (HERC) Prioritized List of Health Services (List) (OAR 410-141-3830); and (d) Referenced guideline notes (The date of service determines the correct version of the administrative rules and HERC List to determine coverage.); and (e) The Authority’s general rules related to provider enrollment and claiming (OAR 943-120-0300 through 1505). (5) Providers must verify that an individual is an OHP member and eligible for benefits prior to providing services to ensure reimbursement for services provided. If the provider fails to confirm eligibility on the date of service, the provider may not be reimbursed. Providers must verify the member’s eligibility including: (a) That the individual receiving vision services is eligible on the date of service for the service provided; (b) Whether an OHP member receives services on a FFS basis or is enrolled with an MCE; (c) That the service is covered under the member’s OHP Benefit Package; and (d) Whether the service is covered by a third party resource (TPR). (6) Providers must maintain accurate and complete member records, which includes documenting the quantity of services provided, as outlined in OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records). For comprehensive eye exams, the standard of care and expectation is that the provider shall provide a dilated exam and document the type of dilating drops and time of dilation. (7) 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. (8) The provider shall inform an OHP member when: (a) Vision service or materials are not covered under the members benefit package; (b) Service limitations have been met and the benefit is no longer covered. (9) Providers must: (a) Verify the member’s eligibility and benefit coverage prior to submitting vision material orders to the contractor; (b) Obtain PA from the Division for items requiring PA prior to placing a vision materials order; (c) Comply with the contractor’s order submission requirements, as outlined in the Visual Services Supplemental Information Guide found at Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx; (d) Submit prescription or order to the contractor upon notification of PA approval from the contractor; and (e) Pay SWEEP Optical for any services, materials, and supplies provided by SWEEP Optical to a member who is not eligible for items. SWEEP Optical may not sell materials and supplies for non-eligible members at the State Contracted Price. (10) Post-operative care provided outside the global package is: (a) Reimbursable to optometrists when furnished within their scope of practice; (b) Billed with: (A) The surgical CPT code billed by the surgeon; (B) The appropriate modifier noting post-operative care only; and (C) The first post-operative date of service; and (c) Reimbursed a percentage of the global reimbursement. (11) Providers are responsible for: (a) Verifying member eligibility prior to submitting an order to the contractor. Refer to OAR 410-120-1140 Verification of Eligibility; (b) Obtaining prior authorization (PA) from the Division for items requiring PA prior to placing a vision materials order. (See OAR 410-140-0040 Prior Authorization.); (c) Complying with the contractor’s order submission requirements, as outlined in the Visual Services Supplemental Information Guide found on this Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx; (d) Submitting prescription/order to the contractor upon notification of PA approval from the contractor; and (e) Paying SWEEP Optical for any services provided by SWEEP Optical to a member who is not eligible for items. SWEEP Optical is prohibited by contract to sell materials and supplies for non-eligible members at the State Contracted Price. (12) 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. (13) It is the provider’s responsibility to contact the member’s PHP of CCO and give them the last date of service. The current PHP or CCO shall then determine if they want to allow for an additional supply of glasses. If the member is an established member, regardless of incomplete information through phone or electronic verification systems or SWEEP Optical, it is the provider’s responsibility to inform the PHP/CCO of the last date of service.