Vision Care Services

(A) Introduction. Vision care services are the professional care of the eyes for purposes of diagnosing and correcting refractive errors, analyzing muscular anomalies, and determining pathological conditions. They include eye examinations, vision training, and the prescription and dispensing of ophthalmic materials. Professional and technical services must be provided in accordance with the established standards of quality and health care necessity recognized by the vision care industry and licensing agencies in Massachusetts. (B) Provision of Vision Care Services. The MassHealth agency pays for vision care services, including the dispensing of ophthalmic materials, provided to MassHealth members by an acute hospital outpatient department, HLHC, or other hospital satellite clinic. These services must be furnished in accordance with, and coverage of such services and related prescription requirements for authorized prescribers are governed by, MassHealth regulations at 130 CMR 402.000: Vision Care Services. Payment is subject to the conditions, exclusions, and limitations set forth in 130 CMR 402.000: Vision Care Services. (C) Payment. Acute hospital outpatient departments and HLHCs are paid pursuant to 101 CMR 315.00: Rates for Vision Care Services and Ophthalmic Materials for services described as ophthalmic materials dispensing in Subchapter 6 of the Vision Care Manual. All other vision care services provided by an acute hospital outpatient department, HLHC, or other hospital satellite clinic are paid according to the outpatient hospital payment methodology established by the signed MassHealth provider agreement. (D) Prior Authorization. (1) For certain vision care services specified in 130 CMR 402.000: Vision Care Services, the MassHealth agency requires the provider to obtain prior authorization as a prerequisite to payment. (2) All prior authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Outpatient Hospital Manual.