Information for Dates of Service Before October 1, 2015

Contact Lenses for Members with a Diagnosis of Aphakia or Keratoconus

Documentation Requirements

Providers are required to include specific documentation when submitting claims for contact lenses for members with a diagnosis of aphakia or keratoconus. The documentation includes all of the following:

• The lab cost of the lenses. Attach a copy of the invoice for the lenses or a copy of the catalog page with the specific lens highlighted or underlined.
• The amount of the provider's usual and customary dispensing fee.
• The specifications of the contact lenses. Providers should include the following for each lens:
  • Base curve.
  • Diameter.
  • Power.
  • Material.
• The contact lens manufacturer.
• Whether it is an initial fitting or replacement lenses.

All claims for contact lenses are reviewed by BadgerCare Plus. Claims submitted without the required information will be returned to the provider with a request for the necessary documentation. The additional documentation establishes the pricing of the contact lenses. A diagnosis of aphakia or keratoconus does not guarantee payment for contact lenses. Contact lenses must be medically necessary and the provider is required to submit a correct claim.

Prior Authorization

Applicable Procedure Codes

The following table lists the allowable procedure codes when submitting claims for contact lenses for members with a diagnosis of aphakia or keratoconus.

Applicable Diagnoses

The following table lists the allowable diagnoses when submitting claims for contact lenses for members with a diagnosis of aphakia or keratoconus.