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Requests for Extended Ophthalmoscopy

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Extended Ophthalmoscopy

According to the American Academy of Pediatrics (AAP)’s 2018 guidance Screening Examination of Premature Infants for Retinopathy of Prematurity, infants born premature or with low birth weight are at risk for developing retinopathy of prematurity (ROP). Because of the usually predictable and sequential nature of ROP progression, and the proven benefits of timely treatment in reducing the risk of vision loss, efficacious care now requires that infants who are at risk receive carefully timed retinal examinations to identify treatment-requiring ROP in time for that treatment to be effective.

Texas Medicaid Vision Services policy currently limits coverage of ophthalmoscopy (procedure codes 92201 and 92202) to two services per year. With evidence of medical necessity, additional screening examinations of premature infants for retinopathy of prematurity must be considered through the Texas Health Steps-Comprehensive Care Program (CCP).

Texas Health Steps-CCP is an expansion of the Early Periodic Screening, Diagnosis, and Treatment service as mandated by the Omnibus Budget Reconciliation Act of 1989, which requires states to provide all medically necessary treatment for correction of physical or mental health conditions to Texas Health Steps-eligible clients (birth through 20 years of age) when federal financial participation (FFP) is available.

Prior authorization of CCP services is required and may be requested in writing by completing the appropriate request form, attaching any necessary supportive documentation, and submitting them by mail, fax, or the electronic portal to the TMHP-CCP department. For clients enrolled in managed care, providers should refer to the client’s specific MCO for prior authorization details.

Additional information on Texas Health Steps-CCP is available in the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Section 2, “Medicaid Children’s Services Comprehensive Care Program (CCP).”

For more information, call the TMHP Contact Center at 800-925-9126.