Effective July 1, 2006, the Date of Appliance Delivered will no longer be required on the CMS 1500 claim form. However, providers are required to maintain the following information in the medical record: Medi-Cal recipient’s printed name and signature, signature and printed name of the person receiving the eye appliance, date signed, item description of the eye appliance dispensed, and relationship of the recipient to the person receiving the prescription if the recipient is not picking up the eye appliance.

Medi-Cal is always the last entity billed. OHC carriers should be billed first.

Providers are instructed to enter Medicare status codes for Charpentier claims in Box 22 of the CMS 1500 claim form. Please refer to the CMS 1500 Completion for Vision Care section in the Medi-Cal Vision Care Provider Manual for a list of Medicare status codes.

Providers should always obtain a signed statement from the patient when eyeglasses are replaced before the 24-month benefit period ends. The statement must certify that a loss, breakage or damage was beyond the recipient’s control and must include the circumstances of the loss or destruction and the steps taken to recover the lost item. A recipient’s signed statement about the circumstances of replacement must be retained in the recipient’s file for at least three years.

In addition to documentation of medical necessity in the medical chart, providers may be required to also submit the following documentation with claims for the repair or replacement of eye appliances if frequency limits are exceeded: the recipient’s name; the date; the circumstances for repair or replacement; a statement certifying that a loss, breakage or damage was beyond the patient’s control; the steps taken to recover the lost item; the recipient’s signature and/or the signature of recipient’s representative or guardian.

CPT-4 code 92015 (determination of refractive state) is a Medicare non-benefit and should be billed directly to Medi-Cal.

The recipient’s phone number is an optional field on the 50-3 TAR form.

The name and address of the recipient’s authorized representative is requested, but not required on the 50-3 TAR form. The authorized representative’s signature is not required.

No, providers can only view those claims submitted using IPCS.

No, crossover claims cannot be submitted using IPCS.

Yes, the 45-1 claim form will still be available because it must be used for claims with dates of service prior to July 1, 2006.

Each claim line is adjudicated individually like a separate claim. Therefore, it is not uncommon for claim line items on the same CMS 1500 claim form to be paid on different dates.

Yes, the name field is one of the fields where the use of a dash is acceptable.

Medi-Cal only recognizes two ICD-9-CM diagnosis codes on the CMS 1500 claim form. Therefore, when billing multiple procedures that require more than two diagnosis codes, separate claims must be billed.

No, the recipient’s signature is not required on the CMS 1500 claim form.

HCPCS codes V2300 to V2321 (trifocal, glass or plastic) and CPT-4 code 92342 (fitting of spectacles, except for aphakia; multifocal other than bifocal) require both modifiers –RP (replacement and repair) and –KX (specific required documentation on file) on the claim for payment or the claim will be denied.

No, TARs are required only for medically necessary contact lenses and evaluations, low vision aids with a retail cost over $100, and non-Prison Industry Authority (PIA) covered items.

No, however, you need to enter the TAR Control Number and Pricing Indicator in the Prior Authorization Number field (Box 23) of the CMS 1500 claim form.

Yes. To obtain a three-digit submitter number, you must complete and return a Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) form. More information about CMC submission can be found in the Computer Media Claims (CMC) Submission section at the bottom of the Medi-Cal FAQs page.

To submit paper attachments linked to a claim submitted using IPCS, providers must use a Medi-Cal Claim Attachment Control Form (ACF) as the coversheet for the supporting attachments. The ACF has a pre-printed Attachment Control Number (ACN), which providers input during their electronic claim submission in a specified field.

Providers submit the electronic claim and mail or fax the ACF along with the paper attachments to Medi-Cal. Medi-Cal then links the paper attachments and electronic claim for processing. Providers have a maximum of 40 calendar days after the electronic claim is submitted to mail or fax the ACF along with the supporting documentation to Medi-Cal.

To fax the attachment, providers submit the electronic claim and fax the ACF along with the attachments to Medi-Cal. Each ACF and its corresponding attachments require a separate fax call. Each call to the fax server must include one ACF as the first page followed by the attachment pages that correspond to that ACF. Additional ACFs and attachments must be sent as separate calls to the fax server. The phone number to fax attachments is 1-866-438-9377.

Providers may also send hard copy attachments by mail. For details on how to send attachments, along with the address to mail the attachments to, please refer to the Billing Instructions section of the 837 Version 4010A1 Health Care Claim Companion Guide.

To begin using the new process, providers will need a supply of ACFs and ACF envelopes, which can be ordered by calling the Telephone Service Center (TSC) at 1-800-541-5555.

As with any fax, the provider should receive a ”successful transmission” message when the fax goes through. There is no other message or notification specifically from EDS.

Eye examination codes (CPT-4 codes 92002, 92012, 92004, and 92014) and Evaluation and Management (E&M) office visit codes (CPT-4 codes 99201-99215) do not require a modifier for payment. Refer to the Modifiers Used with Vision Care Procedure Codes (modif used vc) section of the Medi-Cal Vision Care Manual for a list of modifiers and their corresponding procedure codes. Procedure codes not on this list do not require a modifier.

The base lens codes for glass and plastic lenses (HCPCS codes V2100-V2121, V2200-V2221, and V2300-V2321) should be used only for fee-for-service Medi-Cal recipients in the two non-Prison Industry Authority (PIA) contracted counties of San Mateo (County 41) and Santa Barbara (County 42). In the other 56 counties in California, use only lens dispensing codes (92340-92342 and 92352-92353) when the optical order is produced at the PIA optical laboratories.

The TAR 50-3 form can be faxed to (916) 440-5640 or mailed to:

Department of Health Care Services
Vision Care Policy Unit
P.O. Box 997413, MS 4600
Sacramento, CA 95899-7413

To order the TAR 50-3 form, please call theTelephone Support Center (TSC) at 1-800-541-5555. Once connected, enter prompts 11, 14 and 12 to connect to an operator who can assist you with the form order. Providers should have their Medi-Cal number ready when ordering.

As of July 1, 2006, PIA is no longer supplying frames; therefore, there is no national crosswalk for HCPCS code Z2936. However, HCPCS code Z2936 can still be billed when PIA supplied the frames for dates of service prior to July 1, 2006.