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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 4 Vision Care Professionals : 4.5 Claims Filing and Reimbursement : 4.5.2 Reimbursement

4.5.2
Providers must reflect the highest level of specificity for vision related diagnosis on claims or other documentation. Professional services by an optometrist for contact lenses and prosthetic eyewear are reimbursed in accordance with 1 TAC, §§355.8001, 355.8081, and 355.8085.
FQHCs are paid an all-inclusive rate per visit for payable services in accordance with 1 TAC, §355.8261.
Suppliers of nonprosthetic lenses and frames are reimbursed the lesser of their billed amount or of the established maximum allowable fee in accordance with 1 TAC, §355.8001. See the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.
Refer to:
Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.
Vision Services on the TMHP website at www.tmhp.com for a claim form example.
The nonsurgical vision procedure codes included in this handbook may be subject to the CMS NCCI relationships.
Refer to:
The CMS website at www.cms.gov for more information about NCCI relationships.
Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Texas Medicaid & Healthcare Partnership
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