1 TAC § 354.1021. Additional Claims Information Requirements, DIVISION 2. MEDICAID VISION CARE PROGRAM

Providers must meet the claim criteria established in the provisions of this division for optometric services and the provisions for participation in the Medicaid program established under Division 1, Medicaid Procedures for Providers, and Division 11, General Administration, of this subchapter. In addition to the claims information requirements established in §354.1001 of this subchapter (relating to Claim Information Requirements), the following information is required for claims for vision care services:

(1) name, address, and Medicaid provider identification number of the ordering provider, as appropriate;

(2) description of lenses and frames provided;

(3) provider's signature on the claim form, including degrees or credentials, verifying the diopter or axis changes required for the dispensing of replacement eyewear;

(4) claims for eyewear with special features must be accompanied by a signed form by the recipient that acknowledges his selection of eyewear that is beyond the specifications for eyewear in §354.1017 of this division (relating to Specifications for Eyewear). A signed patient certification satisfies this requirement for claims that are electronically submitted;

(5) if the claim is for replacement of prosthetic eyewear that was lost, stolen, or damaged beyond repair, the recipient must sign the claim form or, in the case of providers who electronically bill, a patient certification; and

(6) if the claim is for vision care services provided to a Medicaid recipient residing in a skilled nursing facility or an intermediate care facility, the claim must indicate the name of the physician who ordered the services and the name of the facility where the recipient resides as the place of service.