TMPPM 2008 > Texas Medicaid Services > Vision Care (Optometrists, Opticians) > Benefits and Limitations

45.4.4.4 Contact Lenses

The Texas Medicaid Program allows reimbursement for contact lenses when no other option is available to correct a visual defect. Prior authorization is mandatory and must be received before dispensing the lens(es), unless the diagnosis is aphakia. Additionally, the client must be eligible for Medicaid at the time the lens(es) are dispensed. Providers must include the following information in each prior authorization request for contact lens(es):

•The client's name and Medicaid number, as they appear on the Medicaid card.

•The diagnosis causing the refractive error (for example, keratoconus).

•The current prescription (also include the previous prescription, if the request is because of a significant change in vision).

•The indication of the eye to be treated (right, left, or bilateral).

•The specific procedure code for contact lens(es) requested.

•A brief statement addressing the medical need for contact lens(es) (specify why eyeglasses are inappropriate or contraindicated for this client).

•The provider identifer.

•The signature of the physician or optometrist requesting prior authorization.

Requests lacking this information will be denied. Mail or fax the request to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: 1-512-514-4213

Soft bandage plano lenses may be dispensed and billed to the Texas Medicaid Program in an emergency situation without prior authorization. The claim must document the medical emergency.

Replacement contact lenses are a benefit for lost or destroyed contact lenses for clients younger than 21 years of age when prior authorized by TMHP. Clients eligible for Medicaid may receive new nonprosthetic contact lenses when there is a significant change in visual acuity (equal to or greater than 0.5 diopter in one eye) and when prior authorized by TMHP.

When billing for bilateral lenses, providers are to use the appropriate code for unilateral lens and specify a quantity of 2 in Block 24E of the claim form.

Refer to: "Nonprosthetic Eyeglasses and Contacts" .

The Vision Claim Form Example on page D-36

"Prosthetic Eyeglasses and Contacts" .