Author: GDIT, (800) 688-6696
Subsection 7.2, Provision of Service, in Clinical Coverage Policies 6A: Routine Eye Examination and Visual Aids for Beneficiaries Under 21 Years of Age and 6B: Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older, the following requirement is stated:
Optical providers shall extend the services of routine eye exams and visual aid fitting and dispensing for a North Carolina Medicaid and NC Health Choice beneficiary if these same services are extended to a private patient in the same practice or business.
a. If both routine eye exams and visual aids are not available in the provider’s office for all patients, the provider shall inform the beneficiary prior to services being offered or scheduled. The beneficiary shall be given the option to select a provider who will provide both services.
b. If the beneficiary elects to have the exam, a written prescription for the lenses must be given or offered to the beneficiary at the time of the exam. The prescribing provider shall not withhold the prescription pending payment for the routine eye exam or previously unpaid Medicaid or private bills.
In summary, providers must provide routine eye exams and visual aids (eyeglasses and contact lenses) for Medicaid and NC Health Choice beneficiaries if both services are provided for non-Medicaid and non-NC Health Choice patients in the same practice or business location. If a provider does not provide visual aids for any patient, the provider must inform Medicaid and NC Health Choice beneficiaries that visual aids are not available before a routine eye exam is scheduled. Once the routine eye exam is completed, providers must release the written prescription, prior to receiving payment from NC Medicaid.
For more information, please refer to Clinical Coverage Policies 6A: Routine Eye Examination and Visual Aids for Beneficiaries Under 21 Years of Age and 6B: Routine Eye Examination and Visual Aids for Beneficiaries 21 Years of Age and Older. Policies can be found at: https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies.