1. (A) A vision care provider must maintain a suitable medical record for each member for a period of as long as the minimum period required by 130 CMR 450.205(G). The record must fully disclose all pertinent information about the services furnished, including the date of service, the dates on which materials were ordered and dispensed, and a description of materials ordered and dispensed (including the frame style and the manufacturer's name). All findings resulting from vision care services, whether they are normal or abnormal, must be recorded. When extenuating circumstances prevent the use of one or more procedures normally performed in vision care services, the record must contain the reasons that the tests were not performed.

2. (B) For comprehensive vision care examinations and diagnoses performed in the office, a nursing facility, a hospital, or the member's home, the record must contain the following information or test results:

   1. (1) case history;
   2. (2) visual acuity testing;
   3. (3) ophthalmoscopy and external eye health examination;
   4. (4) ocular mobility testing, heterophoria testing, and fusion testing;
   5. (5) pupillary reflex testing;
   6. (6) refraction (objective, subjective refraction, and keratometry);
   7. (7) confrontation fields or other screening tests;
   8. (8) tonometry;
   9. (9) case analysis and disposition; and
   10. (10) biomicroscopy.

3. (C) All consultation services must be fully documented in the record. A record for a consultation must contain the following information:

   1. (1) the member's complaints and symptoms;
   2. (2) the condition of the eye; and
   3. (3) if applicable, the name of the person to whom a referral was made.

4. (D) All screening services must be fully documented in the member’s record. A record for a screening service must note the chief complaint and must contain all findings of two or more of the following tests:

   1. (1) distance vision and near vision;
   2. (2) cover test;
   3. (3) visual skills;
   4. (4) tonometry;
   5. (5) biomicroscopy.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-8

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

402.418: Services Provided outside the Office

1. (A) Member's Home. The MassHealth agency pays for vision care services provided to a member in the member's home. A medical record must be kept on file at the provider's office.
2. (B) Nursing Facility. The MassHealth agency pays for vision care services for a member residing in a nursing facility only when the service is specifically requested by the medical director, the nursing director, or responsible staff member at the facility, or by the member's personal physician. The request must be documented in the member's record at the facility. If eyeglasses or other visual aids are to be dispensed to a member in the facility, the facility must document in the member's record that a consultation has occurred between the facility's staff member and the vision care provider, and that they have determined that the member is able to benefit from eyeglasses or other visual aids. A copy of the eye examination results, including the prescription, must be filed in the member's record at the facility and at the vision care provider’s primary office location.
3. (C) Other Facilities. The MassHealth agency pays for vision care services provided to a member residing in a public or private facility, if payment for these services is not included in the facility's rate. A medical record must be kept on file at the provider's office.
4. (D) Other Locations of Service. The MassHealth agency pays for vision care services provided to eligible members at other places of service as approved by the MassHealth agency.

5. (E) Claims for Payment.

   1. (1) A vision care examination performed for a member outside of the office must be claimed using the appropriate service codes. (See Subchapter 6 of the Vision Care Manual.)
   2. (2) The MassHealth agency pays separately for transportation once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office in accordance with 130 CMR 402.418(A) through (D).

(130 CMR 402.419 through 402.425 Reserved)

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-9

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24

402.426: Service Limitations: Eye Examinations

(A)(1) The MassHealth agency does not pay for a comprehensive eye examination in an optometrist's office or a visual analysis in a home or nursing facility if a comprehensive eye examination or a visual analysis has been furnished:

1. (a) within the preceding 12 months, for a member younger than 21 years old; or
2. (b) within the preceding 24 months, for a member 21 years of age or older.

3. (2) These restrictions do not apply if there is a referral from the member's physician or if one of the following complaints or conditions is documented in the member's record:

   1. (a) blurred vision;
   2. (b) evidence of headaches;
   3. (c) systemic diseases such as diabetes, hyperthyroidism, or HIV;
   4. (d) cataracts;
   5. (e) eye pain;
   6. (f) eye redness;
   7. (g) eye infection;
   8. (h) double vision; or
   9. (i) members receiving long-term therapeutic drugs which may cause ocular side effects.

1. (B) The MassHealth agency pays for a consultation service only if it is provided independently of a comprehensive eye examination.
2. (C) The MassHealth agency does not pay for more than two screening services per 12-month period.
3. (D) A comprehensive eye examination includes a screening service. The provider cannot bill separately for both a screening service and a comprehensive eye examination for the same member. The MassHealth agency pays for only the comprehensive eye exam.
4. (E) The MassHealth agency does not pay for a tonometry as a separate service when it is performed as part of a comprehensive eye examination, a consultation, or a screening service. When a tonometry is performed as a separate service to monitor a member who has glaucoma, the provider must use the appropriate service code (see Subchapter 6 of the Vision Care Manual).

402.427: Service Limitations: Dispensing Eyeglasses

1. (A) The MassHealth agency pays for only one initial pair of eyeglasses and only if there is a corrective power of at least +.75D sphere or +.50D cylinder. (See 130 CMR 402.431 for an exception which permits two pairs of eyeglasses instead of bifocals and 130 CMR 402.434 regarding spare eyeglasses.)
2. (B) The MassHealth agency pays for new eyeglasses for a member younger than 21 years old every 12 months and for a member 21 years of age or older every 24 months with a prescription that meets the standards set at 130 CMR 402.427(A).

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-10

Provider Manual Series (130 CMR 402.000)

Transmittal Letter Date

Vision Care Manual

VIS-45 02/02/24