Medical, Dental & Pharmacy
- Medical
- Ambulatory Surgical Services
- Children's Services
- Chiropractic
- Clinic Services
- Community First Services and Supports (CFSS)
- Early Intensive Development and Behavioral Intervention (EIDBI)
- Equipment and Supplies
- HCBS
- Hearing Services
- Home Care Services
- Hospice Services
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Laboratory/Pathology, Radiology, and Diagnostic Services
- Language Interpreter Services
- Long-Term Care
- Medication Reconciliation
- Mental Health Services
- Optical Services
- Personal Care Assistance (PCA) Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitation Services
- Renal Dialysis
- Restricted Recipient Program
- School-Based Community Services
- Substance Use Disorder
- Telehealth Services
- Transportation
- Tribal and Federal Indian Health Services
- Dental
- Pharmacy
Eyeglasses
- For initial eyeglasses to be medically necessary, there must be a correction of .50 diopters or greater in either sphere or cylinder power in either eye. Diopter is the unit of refracting power of the lens.
- Lenses covered by PrimeWest Health must be first quality impact resistant glass, plastic or polycarbonate single vision, bifocal, or trifocal lenses.
- Lenses must conform to the American National Standards Institute (ANSI) “Recommendation for Prescription Ophthalmic Lenses,” ANSI’s most current standards, and the United States Food and Drug Administration (FDA) requirements for impact resistance.
- All lenses must be finished (hardened and edged) and assembled in the frame.
- A new eyeglass case must be included with each pair of eyeglasses.
- Eyeglasses found by the member to be unsatisfactory due to defective workmanship and/or materials must be replaced or repaired by the provider without cost to the member or PrimeWest Health.
- Errors made in prescribing or dispensing are the responsibility of the prescribing and/or dispensing provider and are not to be billed to PrimeWest Health or the member.
Eyeglass Frames
All eligible PrimeWest Health members may select any approved standard frame. Members under age 21 and adult members with cognitive disabilities or seizure disorders may select approved deluxe frames. When a deluxe frame is ordered for a member age 21 or over, the provider must include an appropriate diagnosis code on the claim.
Members may select approved frames without lenses when purchasing non-covered lenses. The provider must be able to mount the non-covered lenses in the frames. The provider must clearly inform the member that the frames will be covered; however, all costs associated with the non-covered lenses and mounting of the lenses will be the member’s responsibility.
If a member chooses to purchase upgraded frames (such as a more fashionable frame), the member is responsible for the entire cost of the frames. The member cannot pay for the difference of the upgrade. The provider can only bill PrimeWest Health for the covered lenses.
PrimeWest Health will not pay for the dispensing fee, repairs, or adjustments made to upgraded products or non-covered items.
Bill services provided to PrimeWest Health members using the 837P format for all services.
Eyeglass Lenses
Members with medical conditions that may be affected or aggravated by bright or changing light conditions may require tinted, UV, polarized, or photochromatic lenses. Specialty lenses are covered for members with albinism, achromatopsia, aniridia, blue cone monochromatism, cystinosis, or retinitis pigmentosa. When specialty lenses are ordered, the provider must include an appropriate diagnosis on the claim. A Service Authorization is required before providing polarized lenses.
Members may request covered lenses for member-owned frames. If a member chooses to purchase upgraded lenses that are not medically necessary (such as high-index plastic, transition lenses, no-line bifocals), the member would be responsible for the entire cost of the lenses. The member cannot pay for the difference of the upgrade. The provider may only bill for the covered frames.
PrimeWest Health will not pay for the dispensing fee, repairs, or adjustments made to upgraded products or non-covered items.
Bill services provided to PrimeWest Health members using the 837P format for all services.
PrimeWest Health Senior Health Complete and Prime Health Complete members may be eligible for additional supplemental benefits for eyeglasses. Review the Supplemental Benefits guide for more information.
Medical Necessity Criteria for Receiving Eyeglasses More Frequently than Every Two Years
It is expected that with reasonable care, eyeglasses should not need to be replaced due to loss or damage more than once in a two-year dispensing period. However, vision providers may dispense new eyeglasses, even though two years have not passed since the member’s last pair was dispensed. PrimeWest Health members are able to obtain a second pair of eyeglasses within the two-year dispensing period without a Service Authorization as long as the one or more of following criteria is met:
- There is a change in correction of 0.5 diopters or greater in either sphere or cylinder power in either eye
- There is a shift in axis of greater than 10 degrees in either eye
- A comprehensive or intermediate vision examination shows that a change in eyeglasses is medically necessary
- There is a change in the member’s head size that warrants a new pair of eyeglasses
- The member has had an allergic reaction to the previous pair of eyeglasses
- The original pair is lost, broken, or irreparably damaged. If the original pair is lost, broken, or damaged beyond repair, the eyeglasses will be replaced with an identical pair of eyeglasses, unless the identical frame is not available. The original pair must also be the first pair of eyeglasses provided in a dispensing period.
- The member is a child (up to 21 years of age).
PrimeWest Health reserves the right to deny coverage for a second pair for eyeglasses if, upon review of the medical record, there is no documentation that the replacement criteria were met. A backup pair of eyeglasses is not covered.
A Service Authorization is required for all members, including Prime Health Complete and SNBC members, before providing a member with more than two pairs of eyeglasses in a two-year dispensing period. If the eyeglasses are lost, broken, or damaged beyond repair, the eyeglasses will be replaced with an identical pair of eyeglasses, unless the identical frame is not available (in which case a different frame will be substituted). The dispensing provider must obtain a written statement from the member (or the member’s caretaker) explaining why the eyeglasses were broken, lost, or can’t be repaired, and must send a copy of this documentation to PrimeWest Health with the Service Authorization request.
Repairs/Replacement
Billing for Repairs/Replacement
Repairs made to frames and lenses not under warranty may be billed to PrimeWest Health. Only frames and lenses purchased through PrimeWest Health are covered for repairs.
- Bill replacement frame or lenses using the appropriate frame or lens code with modifier RA. Do not bill a dispensing code for replacement of just the frame or lenses.
- A dispensing fee may only be billed if you are replacing a complete set of glasses (lenses and frame). Bill repairs to frames using either code 92370, repair and refitting of spectacles, or 92371, repair of spectacle prosthesis for aphakia. These codes will not require any additional modifiers. Do not bill a dispensing code for repairs.
- Bill dispensing fees only for complete set of frame and lenses, and only once within a 30-day period.
Please note: The RP modifier is invalid.
PW_11-19_572
Updated_12/18/2024
