March 24, 2011

Dear Colleagues,

On March 22nd, the Budget and Control Board approved the full deficit budget for South Carolina Department of Health & Human Services.  This approval will allow the state's Medicaid agency to continue reimbursing providers without interruption for the remainder of this fiscal year.  There will still be changes in the future for the Medicaid program, but for now there is no longer the possibility of cessation of payments.

I am listing the answers to several questions and situations that arose over the last month. These apply to adults over 21, who are enrolled in Medicaid Fee-for-Service or in a Medical Home Network.

1.  Medicaid will not reimburse for glasses of any sort.  This includes full reimbursement or partial reimbursement for post-cataract surgery glasses.

2.  Medicaid will not reimburse for contact lenses of any sort, including keratoconus contact lenses.

3.  Medicaid will only reimburse for medically necessary services.  Currently, there is not a set of ICD-9 codes that Medicaid has as a reference for medically necessary services.  However, a good comparison for these codes would be the same codes that Medicare uses to reimburse claims.

4.  Medicaid will not reimburse for routine vision in any form.  If there is a routine vision diagnosis code or CPT code on the claim filed to Medicaid, it will be rejected regardless of whether there is also a medical diagnosis code for that patient.  

5.  Medicaid members who have a DMR waiver are considered to have the same benefits as a child under 21.  These members do have routine vision benefits regardless of age.

6.  There are currently three Medical Home Networks operating within the Medicaid program-SC Solutions, Palmetto Physicians Connection, and Carolina Medical Homes.  These adult members only have medically necessary services and no routine vision benefits.  Unlike a Managed Care Organization, optometrists do not have to enroll or be credentialed by a Medical Home Network to provide services.  If you are a Medicaid provider, you may examine the MHN member and then send the claim to Medicaid for reimbursement.

7.  Select Health/First Choice, one of the Medicaid MCOs, will no longer contract with Vision Care Group to administer their network and reimburse claims.  Instead, they will contract with VSP to administer routine vision and medical services.  Please click here to review a notice from Select Health.

8.  There was an initial glitch in the system that caused many claims to be denied.  This glitch has been been fixed and all medically necessary claims should be correctly processed.  However, if there are any issues with rejected claims that have been denied when a medical service has been preformed, please contact Jeremy Harper at 803-898-2544.

If anyone has any questions please do not hesitate to call me or any other SCOPA board members.

Philip Flynn, OD
2757 Laurel St.
Columbia, SC 29204
Office-803-799-7358
Cell-803-530-5290