Sec. 10.09.14.06. Preauthorization Requirements

A. The following services require written preauthorization:

(1) Optometric examinations to determine the extent of visual impairment or the correction required to improve visual acuity before expiration of the normal time limitations;

(2) Replacement of eyeglasses due to medical necessity or because the eyeglasses were lost, stolen, or damaged before expiration of the normal time limitations;

(3) Contact lenses;

(4) Subnormal vision aid examination and fitting;

(5) Orthoptic treatment sessions;

(6) Plastic lenses costing more than equivalent glass lenses unless there are six or more diopters of spherical correction or three or more diopters of astigmatic correction;

(7) Absorptive lenses, except cataract;

(8) Ophthalmic lenses or optical aids when the diopter correction is less than:

(a) -0.50 D. sphere for myopia in the weakest meridian;

(b) +0.75 D. sphere for hyperopia in the weakest meridian;

(c) +0.75 additional for presbyopia;

(d) ±0.75 D. cylinder for astigmatism;

(e) A change in axis of 5° for cylinders of 1.00 diopter or more;

(f) A total of 4 prism diopters lateral or a total of 1 prism diopters vertical.

B. Preauthorization is issued when:

(1) Program procedures are met;

(2) Program limitations are met;

(3) The provider submits to the Department adequate documentation demonstrating that the service to be preauthorized is medically necessary.

C. Preauthorization is valid only for services rendered or initiated within 60 days of the date issued.

D. Preauthorization normally required by the Program is waived when the service is covered and approved by Medicare. However, if the entire or any part of a claim is rejected by Medicare, and the claim is referred to the Program for payment, payment will be made for services covered by the Program only if authorization for those services has been obtained before billing. Non-Medicare claims require preauthorization according to §§A-C of this regulation.