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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.10 Vision Claim Form

All vision services must be billed on a CMS-1500 paper claim form or the appropriate electronic formats. Vision claims submitted on other forms are denied with EOB 01145, “Claim form not allowed for this program.”
For eyewear claims beyond program benefits, (e.g., replacing lost or destroyed eye wear), providers must have the patient sign the “Patient Certification Form” and retain in their records. Do not submit form to TMHP.
Refer to:
The following table shows the blocks required for vision claims on a CMS-1500 paper claim form.
Enter the patient’s last name, first name, and middle initial as printed on the Your Texas Benefits Medicaid card.
Enter numerically the month, day, and year (MM/DD/YYYY) the client was born. Indicate the patient’s sex by checking the appropriate box.
24D, Line “5” for new prescription
24D, Line “6” for old prescription
Check “YES” or “NO”

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.