Contractor Services/Provider Ordering
(1)The Division of Medical Assistance Programs (Division) contracts with SWEEP Optical Laboratories (also referred to herein as contractor) to provide vision materials and supplies. Providers needing materials and supplies must order those directly from the contractor, except when the Oregon Health Plan client has primary Medicare coverage. See OAR 410-140-0080 (Medicare/Medicaid Assistance Program Claims).
(2)Providers are responsible for:
(a)Verifying client eligibility prior to submitting an order to the contractor. Refer to OAR 410-120-1140 (Verification of Eligibility and Coverage) Verification of Eligibility;
(b)Obtaining prior authorization (PA) from the Division for items requiring PA prior to placing a vision materials order. (See OAR 410-140-0040 (Prior Authorization) Prior Authorization.);
(c)Complying with the contractor’s order submission requirements, as outlined in the Visual Services Supplemental Information Guide found on this Division website: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Vision.aspx;
(d)Submitting prescription/order to the contractor upon notification of PA approval from the contractor; and
(e)Paying SWEEP Optical for any services provided by SWEEP Optical to a client who is not eligible for items. SWEEP Optical is prohibited by contract to sell materials and supplies for non-eligible clients at the State Contracted Price.
(3)The contractor’s responsibilities:
(a)Forward Division prior authorization approval to the provider;
(A)The contractor shall provide the order as specified by the ordering provider;
(B)The contractor shall be responsible for all shipping and handling charges for shipments to the provider via United States mail or United Parcel Service for all returned orders that are not to the specifications of the order or that are damaged in shipping;
(C)The contractor may not accept initial orders via telephone. The contractor shall accept telephone calls or faxed messages regarding orders that are not made to specifications;
(D)When the contractor is notified of an item to be returned due to the item not being made to specifications in the original order, the contractor shall begin remaking the product as soon as they are notified, whether or not they have received the item being returned. (The ordering provider shall return the original product to the contractor with a written explanation of the problem and indicate the date they notified the contractor to remake the order.);
(c)Original order delivery:
(A)Delivery Date: The contractor shall deliver the original order of materials and supplies to the ordering provider within seven business days of the date the order is received;
(B)Delay: In the event of a delay in manufacturing or delivery, the contractor shall:
(i)Notify the ordering provider within two business days of receipt of the order;
(ii)Include a description of the order, the reason for delay and the revised time of completion and delivery; and
(C)Special Orders: Delivery of special order frames and lenses may exceed the required delivery time. In this event, the contractor shall provide the ordering provider with notice of the anticipated delay, give the ordering provider a projected delivery date, and document the actual delivery time for future reference.
(4)Provider Error: Neither the contractor nor the Division shall be responsible for costs, expenses or for any required rework due to errors by any provider.
(5)The contractor may use the date of order as the date of service (DOS) but may not bill the Division until the order has been completed and shipped.
(6)The contractor shall bill the Division using Health Care Common Procedure Coding System (HCPC) Codes listed in the contract agreement. Payment will be at contracted rates.
(7)The contractor shall include eyeglass cases with every frame. Cases may not be included in orders for only lenses, temples or frame fronts.
(8)Frame Displays: Frames for display purposes may be purchased from the contractor for the same price as frames for glasses negotiated by the Oregon Department of Administrative Services:
(a)A case may not be provided with display frames; and
(b)Quantity, style, size and color of frames should be specified in the order for display frames.
(9)Contractors will have unisex frame styles available and will allow clients to choose any frame regardless of category listed (i.e., women may choose “Girls” frames).
(10)Regardless of verification received via phone or electronic sources, the contractor may not fill orders for clients who do not have coverage or have met their vision benefit. See OAR 410-140-0140 (Vision Services Coverage and Limitations) Vision Services Coverage and Limitations. When glasses are ordered and the client has met their vision benefit for the time period:
(a)The Division will reimburse the provider for the exam only if the client is not an established client of the provider and the client is currently a fee-for-service (ffs) client with vision benefits. See OAR 410-140-0050 (Eligibility and Benefit Coverage) Eligibility and Benefit Coverage;
(b)The provider needs to contact the client’s Prepaid Health Plan (PHP) or Coordinated Care Organization (CCO) if the client is enrolled with a PHP or CCO that contracts with SWEEP Optical. The contractor applies vision limitations included in rule, regardless of changes to a client’s enrollment status. It is the provider’s responsibility to contact the client’s PHP of CCO and give them the last date of service. The current PHP or CCO will then determine if they want to allow for an additional supply of glasses. If the client is an established client, regardless of incomplete information through phone or electronic verification systems or SWEEP Optical, it is the provider’s responsibility to inform the PHP/CCO of the last date of service.
Rule 410-140-0400 — Contractor Services/Provider Ordering,