NC Medicaid Eyeglasses Dispensing Fee Billing and Payment

NC Medicaid Eyeglasses Dispensing Fee Schedule

The complete Optical Fee Schedule can be found at https://medicaid.ncdhhs.gov/providers/fee-schedules/optical-program-fee-schedule.

NC Medicaid Coverage of Eyeglasses Components

Every set of eyeglasses has three components: 1.) frame, 2.) right lens and 3.) left lens. NC Medicaid covers new complete eyeglasses and replacement components. Providers must bill one unit per component. 

NOTE: If a claim is submitted with more than the designated units, any overpayment is subject to recoupment. 

• If a prior approval request for a replacement component is approved prior to the eligibility date for new complete eyeglasses, the following scenarios could be applicable:
• If a frame is broken and the lenses are still in good condition, NC Medicaid replaces the broken frame.  
• If the lenses are damaged or the Rx changes significantly and the frame is still in good condition, NC Medicaid replaces the lenses.  
• If only one lens is damaged or the Rx changes significantly for one eye, NC Medicaid replaces one lens. 

Therefore, there are separate dispensing fees for each component of the eyeglasses (frame and lens).

See NC Medicaid Clinical Coverage Policy 6A - Subsections 5.8.5, Non-Warranty Frame Replacements and 5.8.7, Early Lens Replacement and NC Medicaid Clinical Coverage Policy 6B - Subsections 5.8.4, Non-Warranty Frame Replacements and 5.8.6, Early Lens Replacement for details regarding early component replacement.

Clinical Coverage Policies 6A and 6B can be found at https://medicaid.ncdhhs.gov/providers/clinical-coverage-policies/vision-services-clinical-coverage-policies

Contact

NCTracks Call Center: 800-688-6696