The MassHealth agency determines the appropriate payment for a service requiring individual consideration in accordance with the following standards and criteria: the amount of time required to perform the service; the degree of required to perform the service; the severity and complexity of the member's disease, disorder, or disability; any applicable studies; any complications or other circumstances that the MassHealth agency deems relevant; the policies, procedures, and practices of other third-party insurers; for ophthalmic materials or supplies, a copy of the invoice from the supplier showing the actual acquisition cost. 402.408: Prior Authorization For certain services specified in 130 CMR 402.426 through 402.434, the MassHealth agency requires that the provider of the service obtain prior authorization as a prerequisite to payment. In addition, services that are designated in Subchapter 6 of the with the Vision Care Manual abbreviation "P.A." require prior authorization. These services include but are not limited to the following: certain contact lenses; low-vision aids; unlisted services; high-index lenses; special-needs glasses; polycarbonate lenses for members aged 21 years of age or older, except for members who are amblyopic or monocular; vision training; and fundus photographs. All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Prior authorization determines only the medical Vision Care Manual. necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment. 402.409: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) The MassHealth agency pays for all medically necessary vision care services for EPSDT eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, , without regard to service limitations Diagnostic, and Treatment (EPSDT) Services: Introduction described in 130 CMR 402.000, and with prior authorization. (130 CMR 402.410 through 402.415 Reserved)
The MassHealth agency determines the appropriate payment for a service requiring individual consideration in accordance with the following standards and criteria: the amount of time required to perform the service; the degree of required to perform the service; the severity and complexity of the member's disease, disorder, or disability; any applicable studies; any complications or other circumstances that the MassHealth agency deems relevant; the policies, procedures, and practices of other third-party insurers; for ophthalmic materials or supplies, a copy of the invoice from the supplier showing the actual acquisition cost. 402.408: Prior Authorization For certain services specified in 130 CMR 402.426 through 402.434, the MassHealth agency requires that the provider of the service obtain prior authorization as a prerequisite to payment. In addition, services that are designated in Subchapter 6 of the Vision Care Manual with the abbreviation "P.A." require prior authorization. These services include but are not limited to the following: certain contact lenses; low-vision aids; unlisted services; high-index lenses; special-needs glasses; polycarbonate lenses for members aged 21 years of age or older, except for members who are amblyopic or monocular; vision training; and fundus photographs. All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Vision Care Manual. Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment. 402.409: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) The MassHealth agency pays for all medically necessary vision care services for EPSDT eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services: Introduction , without regard to service limitations described in 130 CMR 402.000, and with prior authorization. (130 CMR 402.410 through 402.415 Reserved)
regs-visioncare.docx