The rates have been corrected in the Feb. 1, 2022, bulletin and are reflected below and remain current at the time of this publication.
NC Medicaid Eyeglasses Dispensing Fee Schedule
| CODE | DESCRIPTION | MAXIMUM ALLOWABLE RATE |
|---|---|---|
| 92370 | Repair and refitting of spectacles, except for aphakia (dispense frame – 1 unit per frame) | $7.15 |
| 92340 | Fitting of spectacles, except for aphakia; monofocal (single vision lens – 1 unit per lens) | $9.92 |
| 92341 | Fitting of spectacles, except for aphakia; bifocal (bifocal lens – 1 unit per lens) | $11.61 |
| 92342 | Fitting of spectacles, except for aphakia; multifocal not bifocal (trifocal lens – 1 unit per lens) | $12.83 |
| 92353 | Fitting of spectacles, prosthesis for aphakia; multifocal (cataract lens – 1 unit per lens) | $13.05 |
The complete Optical Fee Schedule can be found at on the NC Medicaid Program Specific Clinical Coverage Policies webpage.
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.
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 on the NC Medicaid Program Specific Clinical Coverage Policies webpage.
Provider Billing and NC Medicaid Payment for Complete Eyeglasses vs. Components
| EYEGLASSES COMPNENT(S) DESCRIPTION | FRAME | LENSES | MEDICAID PAYMENT |
|---|---|---|---|
| Complete eyeglasses with single vision lenses | 92370 (1 unit) $7.15 |
92340 (2 units) $9.92 x 2 |
$26.99 |
| Complete eyeglasses with bifocal lenses | 92370 (1 unit) $7.15 |
92341 (2 units) $11.61 x 2 |
$30.37 |
| Complete eyeglasses with trifocal lenses | 92370 (1 unit) $7.15 |
92342 (2 units) $12.83 x 2 |
$32.81 |
| Complete eyeglasses with cataract lenses | 92370 (1 unit) $7.15 |
92353 (2 units) $13.05 x 2 |
$33.25 |
| Replacement frame only | 92370 (1 unit) $7.15 |
N/A | $7.15 |
| Replacement single vision lenses (2) | N/A | 92340 (2 units) $9.92 x 2 |
$19.84 |
| Replacement single vision lens (1) | N/A | 92340 (1 units) $9.92 |
$9.92 |
| Replacement bifocal lenses (2) | N/A | 92341 (2 units) $11.61 x 2 |
$23.22 |
| Replacement bifocal lens (1) | N/A | 92341 (1 unit) $11.61 |
$11.61 |
| Replacement trifocal lenses (2) | N/A | 92342 (2 units) $12.83 x 2 |
$25.66 |
| Replacement trifocal lens (1) | N/A | 92342 (1 unit) $12.83 |
$12.83 |
| Replacement cataract lenses (2) | N/A | 92353 (2 units) $13.05 x 2 |
$26.10 |
| Replacement cataract lens (1) | N/A | 92353 (1 unit) $13.05 |
$13.05 |
Contact
NCTracks Call Center: 800-688-6696