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(1) These requirements are in addition to the rule provisions generally applicable to Medicaid providers.

(2) The department hereby adopts and incorporates by reference the definitions found in the introduction of Physicians Current Procedural Terminology, fourth edition (CPT 4), published by the American Medical Association of Chicago, Illinois. These materials set forth meanings of terms commonly used by the Montana Medicaid program in implementation of the program's optometric schedule. A copy of the definitions herein incorporated may be obtained through the Department of Public Health and Human Services, Health Resources Division, P.O. Box 202951, 1400 Broadway, Helena, MT 59620-2951. Providers must bill for services using the procedure codes, and modifiers set forth, and according to the definitions contained in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Health Resources Division at the address stated above.

(3) A Medicaid member under 21 years of age is limited to one eye examination for determination of refractive state per 365-day period. A Medicaid member 21 years of age or older is limited to one eye examination for determination of refractive state per 730-day period unless one of the following circumstances exist:

(a) following cataract surgery more than one examination during the 365-day period is necessary; or

(b) the provider determines by screening that a loss of one line acuity has occurred with present glasses.


History: 53-6-113, MCA; IMP, 53-6-101, 53-6-141, MCA; NEW, 1980 MAR p. 1758, Eff. 6/27/80; AMD, 1987 MAR p. 895, Eff. 7/1/87; AMD, 1988 MAR p. 758, Eff. 4/15/88; AMD, 1989 MAR p. 272, Eff. 3/1/89; AMD, 1997 MAR p. 1269, Eff. 7/22/97; TRANS, from SRS, 2000 MAR p. 481; AMD, 2016 MAR p. 829, Eff. 5/7/16; AMD, 2018 MAR p. 458, Eff. 3/1/18.

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