Eligibility and Benefit Coverage
(1)Providers shall verify that an individual is an OHP client and eligible for benefits prior to providing services to ensure reimbursement for services provided. If the provider fails to confirm eligibility on the date of service, the provider may not be reimbursed. Providers must verify the client’s eligibility including:
(a)That the individual receiving vision services is eligible on the date of service for the service provided;
(b)Whether an OHP client receives services on a fee-for-service basis or is enrolled with a PHP or CCO;
(c)That the service is covered under the client’s OHP Benefit Package; and
(d)Whether the service is covered by a third party resource (TPR).
(2)The Division OHP vision benefit packages:
(a)For non-pregnant adults (age 21 and older):
(A)Visual services and materials to diagnose and correct disorders of refraction and accommodation are covered only when the client has a covered medical diagnosis or following cataract surgery or a corneal lens transplant as described in OAR 410-140-0140 (Vision Services Coverage and Limitations);
(B)Orthoptic and pleoptic training (vision therapy) is not covered; and
(C)Other visual services are covered with limitations as described in this rule.
(b)For pregnant adult women (age 21 and older):
(A)Orthoptic and pleoptic training (vision therapy) is not covered; and
(B)Other visual services are covered with limitations as described in these rules;
(c)For children (birth through age 20): Visual services are covered as described in this rule and without limitation when documentation in the clinical record justifies the medical need.
(3)Providers shall maintain accurate and complete client records, which includes documenting the quantity of services provided, as outlined in OAR 410-120-1360 (Requirements for Financial, Clinical and Other Records) (Requirements for Financial, Clinical and Other Records).
(4)The provider shall inform an OHP client when:
(a)Vision service or materials are not covered under the clients benefit package;
(b)Service limitation has been met and the benefit is no longer covered.
Rule 410-140-0050 — Eligibility and Benefit Coverage,