Provider Administrative Policy
DisclaimerOur provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.
True Blue HMO and Secure Blue PPO Medicare Advantage plan members have an optical benefit above and beyond the Medicare covered post cataract benefit. Because diagnosis codes for both services can be the same, providers are required to identify post cataract hardware.True Blue Freedom (Ada and Canyon County only) does not have an optical benefit beyond Original Medicare coverage or post cataract eyewear.
Post Cataract Hardware
Providers should bill all post-cataract appropriate hardware with the SC* modifier in the primary modifier position. Append this modifier only to the hardware codes and not to physician service codes.
Presbyopia-correcting Intraocular Lens
Following cataract removal a member may request insertion of a presbyopia-correcting intraocular lens (IOL) instead of a conventional IOL.Prior to the procedure, the facility and physician must inform the beneficiary of Medicare's policy to pay for services specific to the insertion, adjustment, or other subsequent treatments related to the presbyopia-correcting functionality of the IOL. Because the presbyopia-correction functionality of a presbyopia-correcting IOL does not fall into a Medicare benefit category, it is not covered. We encourage facilities and physicians to provide members who request a presbyopia-correcting IOL either an Advanced Beneficiary Notice (ABN) or a Notice of Exclusion from Medicare benefits so they clearly understand the non-payable aspects of presbyopia-correcting IOL insertion.
Optical Benefit Hardware
Providers should bill optical services where member benefit is applicable without the SC modifier.
*SC – Medically necessary service or supply
Vision Benefit Application
Claims processed under the vision care benefit will include a vision copayment. This applies to claims billed with 92002, 92004, 92012, or 92014 CPT codes, showing the primary diagnosis as a vision condition (IDC.9.CM 367.0 - 367.9 or V72.0).
We will process claims with a medical diagnosis not included in the code range or CPT list above or with any other Evaluation and Management codes under the member's medical benefit and apply the specialist's office visit copayment.
|March 2012||Revised||Removed copayment amount.|
|January 2012||Revised||Language added regarding Freedome Blue|
|October 2011||Revised||Added benefit after July 29, 2011 includes a $25 copayment.|