Providers must meet the criteria established in this subchapter for optometric services and the provisions for participation in the Medicaid Program established under Chapter 29, Subchapter A of this title (relating to Medicaid Procedures for Providers) and Chapter 29, Subchapter L of this title (relating to General Administration). Besides the claims information requirements established in §29.1 of this title (relating to Claim Information Requirements), the following information is required for claims for optometric services:

1. (1) name, address, and Medicaid provider identification number of the ordering provider, as appropriate;
2. (2) description of lenses and frames provided;
3. (3) provider's signature on the claim verifying the diopter change required for the dispensing of eyeglasses;
4. (4) certification by the provider that the dispensed materials used for repairs meet the specifications for eyewear in §33.403 of this title (relating to Specifications for Eyewear);
5. (5) claims for eyewear with special features, signed by the recipient, acknowledging selection of eyewear that is beyond the specifications for eyewear in §33.403 of this title (relating to Specifications for Eyewear). A signed patient certification satisfies this requirement for claims the provider submitted electronically;
6. (6) a copy of the invoice for supplies dispensed, attached to a claim for repairs or kept the provider, as authorized by the department or its designee;

7. (7) if the claim is for replacement of prosthetic eyewear or of nonprosthetic eyewear when the records of the department or its designee show that less than 24 months have elapsed since the date of the original nonprosthetic eyewear service, then:

   1. (A) submission of a statement justifying the need for the replacement eyewear (reimbursement is made only if the eyewear was lost or damaged beyond repair or if the recipient's visual acuity has changed significantly, as specified in §33.402(3)(B)(i) or (ii)(II) of this title (relating to Benefits and Limitations)). If the original eyewear has been lost or damaged beyond repair, the recipient must sign the claim form or a patient certification if the provider submits claims electronically; and
   2. (B) claim form signed by the recipient if the original eyewear was lost or damaged beyond repair; and
8. (8) prescriptions for plastic lenses, which must include a provider's written justification of the medical necessity for the plastic lenses on the claim form.

Source Note:The provisions of this §363.504 adopted to be effective July 1, 1986, 11 TexReg 2758; amended to be effective July 1, 1987, 12 TexReg 1779; amended to be effective June 15, 1988, 13 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2002, as published in the Texas Register December 6, 2002, 27 TexReg 11527.