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Title: Section 537.4 - Reimbursement for payments to dispensing opticians and other

537.4 Reimbursement for payments to dispensing opticians and other retail optical establishments. (a) The maximum reimbursable allowance for services of dispensing opticians and other retail optical establishments (including salaried optometrists employed by retail optical establishments) shall be as follows:

FEES FOR LENSES AND FRAMES

First or single pair of eyeglasses Code Item Fee Remarks E601 Single vision, standard chart thickness.........** 1 E651 hardening and testing*........................$2.22

prior E661 tinting.......................................** approval

prior E701 Single vision, over-standard chart thickness....** approval

prior E751 hardening and testing*........................$3.70 approval

prior E761 tinting.......................................** approval E801 Bifocals........................................** E851 hardening and testing*........................$4.00

prior E861 tinting.......................................** approval E901 Trifocals.......................................** E951 hardening and testing*........................$4.44

prior E961 tinting.......................................** approval E521 Frame, wholesale cost up to $4.00...............**

prior E621 Frame, wholesale cost more than $4.00...........** approval ________________________________________________________________________ FOOTNOTES: 1) Prior approval required if correction is less than 1/2 diopter. * Hardening, testing and markup (48%) included in this fee. ** Reimbursement at actual wholesale cost to the dispenser plus 48 percent above such cost. The following amounts will be accepted as minimum wholesale costs in computing the markup.

Single vision lenses and frames.................$ 5.50 Bifocal lenses and frames....................... 8.00 Trifocal lenses and frames...................... 13.00 2 Remarks applicable only in the medical assistance program. ________________________________________________________________________

Second pair of eyeglasses (dispensed at same time) Code Item Fee Remarksý E602 Single vision, standard chart thickness.......** E652 hardening and testing*......................$2.22

prior E662 tinting.....................................** approval

prior E702 Single vision, over standard chart thickness..** approval

prior E752 hardening and testing*......................$3.70 approval

prior E762 tinting.....................................** approval E522 Frame, wholesale cost up to $4.00.............**

prior E622 Frame, wholesale cost more than $4.00.........** approval

FEES FOR OTHER SERVICES E500 Examination by a salaried optometrist· to include

diagnosis for optical deficiency and for visual or muscular anomaly of the human eye..........$5.00 {4} E503 Contact lenses--provided for ocular pathology only prior

and recommended by an ophthalmologist.........by report approval E571 Adjustment by other than original provider....$2.00 E581 Repair for replacement of broken parts

(wholesale cost plus wholesale cost plus 60 percent markup over wholesale cost) minimum of........$2.00 ________________________________________________________________________ FOOTNOTES: * Hardening, testing and markup (48%) included in this fee. ** Reimbursement at actual wholesale cost to the dispenser plus 48 percent above such cost. The following amounts will be accepted as minimum wholesale costs in computing the markup.

Single vision lenses and frames.................$ 5.50 Bifocal lenses and frames....................... 8.00 Trifocal lenses and frames...................... 13.00 2) Remarks applicable only in the medical assistance program. 3) "Salaried optometrist" means a qualified optometrist employed by either a retail optical establishment or dispensing optician or a non-profit health service corporation as defined in article IX-C of the State Insurance Law. 4) The eye examination provided by a qualified salaried optometrist to be accepted as the basis for prescription of eyeglasses shall include, as a minimum, the components of an optometric examination contained in section 505.6 of this Title. Eye examinations which do not meet this standard will not be considered acceptable for purposes of payment from funds under public tax-supported medical care programs. Payment of this fee is effective August 1, 1975. ________________________________________________________________________

(b) The fees provided herein (including markup) are intended to cover all services performed by the above providers in connection with the dispensing of eyeglasses and will be considered full payment for services rendered under State-administered programs. Under the medical assistance program, which is administered by local social services districts, these fees (including markup) represent a maximum allowance for purposes of State reimbursement.

(c) Need for two pairs of eyeglasses, one pair for distance and one for near vision, should be uncommon. Such dispensing must be substantiated by the patient's particular needs, such as proven inability to tolerate bifocals, the unusual nature of the patient's correction, physical ailments, and other conditions which make provision of bifocals inadvisable. Two pairs of eyeglasses should not be provided merely as an alternative to bifocals to satisfy an unjustifiable preference on the part of the patient, for personal convenience or for cosmetic purposes.

(d) The following standards shall be observed in providing lenses and frames.

(1) In all claims for payment, the model or style, name, catalog number and name of manufacturer of the lenses and frames supplied must be included.

(2) All lenses, frames and frame parts shall be guaranteed against defects in manufacture or assembly.

(3) Billing may be based on wholesale prescription assembled cost, regardless of origin of finished services.

(4) All claims for payment are subject to audit which must include verification of wholesale costs.

(5) Only first quality frames shall be supplied. The dispenser shall responsible for any needed replacement or repairs that are due to defects in quality or material or workmanship.

(6) Frames provided shall not exceed a wholesale cost of four dollars except, that for clinical reasons documented by the prescribing ophthalmologist or optometrist, a more expensive frame may be approved for an individual. Such exceptions require prior approval by the appropriate medical director and prior authorization by the social services commissioner.

(7) No extra charge shall be made by a dispenser of eyeglasses for future fittings and adjustments if he has dispensed the eyeglasses. Provision for this service has been included in the above fee.

 

Volume

VOLUME C (Title 18)

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