Opticians
are recognized in Kentucky Medicaid as Provider Type 52. In order to
enroll as an Optician with Kentucky Medicaid, see the Kentucky Medicaid Provider Enrollment website.
Covered Services
Opticians help to choose and fit eyeglasses, frames, and contact lenses by following prescriptions from optometrists or ophthalmologists. Professional dispensing services, lenses, frames and repairs. Vision benefits expanded to adults with an effective date of 1/1/2023, all codes payable to adults and children except for V-2722.
KY Medicaid reimburses for no more than one pair of eyeglasses per beneficiary per calendar year unless the eyeglasses are broken or lost , or the eyeglass prescription changes. A prism, if medically necessary, is included in the cost of lenses. Contact lenses which are covered under 907 KAR 1:632 Section 5(1). Safety glasses require documented proof of medical necessity.
More than one (1) pair of eyeglasses per recipient per calendar year require submission of a claim and signed documentation by Optometrists/Ophthalmologists stating the reason the additional pair is required. The provider will submit the claim on paper and attach documentation stating why the second pair of glasses is needed in a calendar year and that document must be signed by the eye doctor or the provider can submit a claim on KYHealth Net, the provider portal, and attach the document required.
Optometrists must meet the coverage provisions and requirements of
907 KAR 1:632 to provide covered services. All services must be performed within the scope of practice for any provider. Providers must follow Kentucky Medicaid regulations and the requirements of the MCO in which they participate. All services must be medically necessary.Non-Covered Services
Kentucky Medicaid does not reimburse for procedures determined not medically necessary, clinically appropriate, or reasonable by the department.
Verify eligibility
Verify eligibility by calling the automated voice response system at (800) 807-1301 or visit the web-based KYHealth-Net.
Reimbursement
Reimbursement for an Optician
is listed on the Kentucky Medicaid fee schedulewhich can be found on the Fee and Rate Schedule Home Page.
Reimbursement for an Optician is defined in regulation
907 KAR 1:631.
A provider may request coverage for a CPT or HCPCS procedure code by submitting a request in writing to the department which includes necessity, CPT or HCPCS code, and expected reimbursement. Any code considered experimental are not covered by Kentucky Medicaid.
Duplication of Service
Kentucky Medicaid will not reimburse for a service provided to a beneficiary by more than one provider of any program in which the same service is covered, during the same time.
Prior Authorization
Each MCO provides prior authorization for its beneficiaries.
No prior authorization is needed for fee-for-service(FFS) beneficiaries.
Claims Submission
Each MCO processes its own claims.
Kentucky Medicaid contracts with Gainwell Technologies to process the Kentucky Medicaid FFS claims. For more information, visit KYHealth-Net.
Coding
Kentucky Medicaid requires Optician providers to bill on a CMS-1500 claim form utilizing the following code types where applicable:
- Current Procedure Terminology (CPT) codes, regulated by the American Medical Association (AMA).
- Healthcare Common Procedure Coding System (HCPCS) codes, regulated by the Centers for Medicare and Medicaid Services (CMS).
- Current Dental Terminology (CDT) codes, regulated by the American Dental Association (ADA).
- International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes, maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS).
Kentucky Medicaid uses the Medicare National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits, the Medicaid Medically Unlikely Edits (MUEs), and the McKesson Claim Check System to verify codes mutually exclusive or incidental.
Claim Appeals
Appeal requests for denied FFS claims must be submitted to Gainwell Technologies. The request must include the Provider Inquiry Form, reason for the appeal, and a hard copy claim.
Please refer to the member's MCO if appealing an MCO claim.
Timely Filing
Claims must be received within twelve (12) months from the date the service was provided, twelve (12) months from the date retroactive eligibility was established, or six (6) months of the Medicare adjudication date if the service was billed to Medicare.
Provider Inquiry Resources
- Billing Questions- Gainwell Technologies, (800) 807-1232, ky_provider_inquiry@gainwelltechnologies.com
- Provider Questions- (855) 824-5615
- Prior Authorization- Gainwell Technologies, (800) 292-2392, (800) 644-5725, (800) 807-8842
- Provider Enrollment, Maintenance, and Revalidation- (877) 838-5085
- KYHealth.net assistance- Gainwell Technologies, (800) 205-4696, ky_edi_helpdesk@gainwelltechnolgies.com
- Pharmacy Questions- (502) 564-6890, dmsweb@ky.gov
- Pharmacy Clinical Support Questions- (800) 477-3071
- Pharmacy Prior Authorization- (844) 336-2676
- Physician Administered Drug (PAD) list- (502) 564-6890
Managed Care Organizations
*Effective Jan. 1, 2025, Anthem is no longer an active Medicaid Managed Care Organization, or MCO, in Kentucky. However, they are responsible for the payment of claims, appeals, or disputes for dates of service up to and including Dec. 31, 2024.