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  Frequently Asked Questions
 
 
General   Materials   Becoming a Medicaid Provider
Claims   Medicaid Coverage    
 
 
  General
   
Which Care Management Organizations (CMO's) were selected by Georgia Department of Community Health (DCH) to provide and manage the health care delivery for Medicaid recipients?
Amerigroup Georgia, Peach State Health Plan (Centene Corporation) and WellCare of Georgia.
   
When will the new program with the CMO's begin?

The State is divided into six regions.

  • The Atlanta region, awarded to Amerigroup Georgia, Peach State Health Plan and WellCare of Georgia, and the Central region, awarded to Peach State Health Plan and WellCare, begins June 1, 2006.

  • The North and East regions, awarded to Amerigroup Georgia and WellCare of Georgia, begins September 1, 2006.

  • The Southeast region, awarded to Amerigroup Georgia and WellCare of Georgia, and the Southwest region, awarded to Peach State Health Plan and WellCare of Georgia, begins September 1, 2006.
Click here for map of six regions.
   
What is Avesis' relationship with Georgia Medicaid and the CMO's?
Amerigroup Georgia, Peach State Health Plan and WellCare of Georgia have all contracted with Avesis to provide the vision network and administration of the vision benefits for their enrolled Medicaid membership.
   
What is the difference between the old program and the new program in the delivery of services to enrollees of Georgia Medicaid?
The primary difference is that addition of routine eye care for adult enrollees.
 
  Becoming a Medical Provider
   
Why should I participate to provide vision services with the Georgia Medicaid program?
By joining as an Avesis Medicaid provider, your practice will render much needed vision services to the Medicaid enrollees in your community. You are also invited to participate, but not required, in various other plans offered through Avesis. There is no cost to join. You will enjoy national exposure of your practice on the Avesis Internet site. And, via your participation with the other Avesis plans, you will be able to service Avesis members who otherwise may not visit your office.
   
Can a doctor of optometry contract just with Avesis or do they have to contract with the CMO's?
Doctors of Optometry contract with Avesis only.
   
If I want to participate in this program what do I need to do?
Contracted Avesis Provider
If you are already a participating provider with Avesis and have a state issued Medicaid provider number, you need only submit to Avesis a completed Provider Contract Addendum for this program. If you are currently contracted with Avesis but do not have a Medicaid number, you will be required to complete an application with the Georgia Department of Community Health, Department of Medical Assistance. Providers must have a Medicaid number or a pending Medicaid number before rendering services to Medicaid enrollees. To expedite your application for a Medicaid number, you should complete the application online at www.ghp.georgia.gov. Once completed online you will be provided a pending Medicaid number that you will need to provide to Avesis.

Non-contracted Avesis Provider
If you are not currently an Avesis provider, both the Avesis application and the state application will need to be completed and sent in along with required credentialing documentation. Credentialing is required and you will be notified once the process is complete.

The Avesis Provider Application and other Georgia Medicaid forms are located on the Georgia Medicaid Forms Page.

You can also find a link to the Georgia Medicaid provider application on the Avesis website. To expedite your application for a Medicaid number, you should complete the application online at www.ghp.georgia.gov. Once completed online you will be provided a pending Medicaid number that you will need to provide to Avesis.

If you have any questions and would like to speak with a provider services representative, call 1-800-231-0979, or email us at recruiting@avesis.com or fax your inquiry to (866) 874-6834.
   
Do we have to re-enroll with GA Medicaid, or do we keep our existing state issued provider ID numbers?
Providers currently contracted by the state with state issued PIN’s do not need to contact the state unless you have a location which has not had its own PIN assigned.
   
If another doctor joins my practice, are they covered to provide Medicaid services under my number?

No, each doctor must have his or her own Medicaid number and must complete an Avesis Provider Application and credentialing. Each doctor must have a Medicaid number before rendering services to Medicaid recipients. If your optical is filing with a separate tax identification number, an application must be completed for the optical as well.
 
  Medicaid Coverage
   
How will I know if a Georgia Medicaid patient is covered by Avesis?
Medicaid members should present their health plan (CMO) identification card. The card should note Avesis for Vision. Sample Member identification cards for each CMO are also included in the Provider Manual.
   
What if the member doesn't have an ID card?

Providers can verify a member's eligibility with Avesis using the member's social security number or last name and date of birth.
   
How do I verify a Medicaid recipient eligibility?

Member eligibility and benefit coverage can be verified four ways:

  1. The Avesis website is available anytime

  2. Interactive Voice Response System (IVR) is available 24 hours a day at
    (866) 234-4806

  3. Avesis Customer Service Department. Representatives are available from
    9:00 AM to 7:00 PM MST Monday through Friday at 1-800-952-6674
    except holidays
  4. Fax for Avesis Eligibility Verification Fax form only (866) 332-1632
   
Is eligibility updated month to month or day to day?
Avesis is scheduled to receive updated eligibility monthly at this time.
   
Will I need an eligibility code to prove eligibility or submit a claim?
Yes you will. Due to the uniqueness of the program Avesis is rolling out for Georgia Medicaid enrollees and the provider community, it will be necessary to obtain an eligibility verification number from Avesis prior to rendering services. The number obtained must be populated on the lab order form, if applicable, as well as on your claim form to ensure prompt claim processing.
   
How often will a Medicaid recipient be eligible for an eye examination and glasses?
Once during a benefit year (365 days).
   
Am I limited in the type of tests I can perform during an eye exam for a Medicaid patient?
You may perform tests and procedures within the scope of your licensure for Optometrists in the State of Georgia and per the Georgia Medicaid Fee Schedule.
   
Is there a benefit for lost or broken glasses?
All eyewear dispensed under this program must carry a 1 year warranty against manufacturer defect. Should a patient present with broken or lost glasses not covered by this warranty, the provider should complete a prior approval request for that member and forward along with any and all pertinent information for review by the Avesis Quality Assurance Committee. A decision will be rendered and the provider informed within five (5) business days.
   
How often will Avesis update eligibility information for the enrollees of Georgia Medicaid?
Since Avesis is a "down stream" contractor, we do not have direct access to enrollment information. It is currently scheduled to be relayed to Avesis once monthly from each of the three CMOs.
   
What procedures will require prior authorization?
At this time, only cataract co-management, medically necessary contact lenses, vision therapy and replacement glasses inside the benefit year will require prior authorization.
   
What diagnosis constitutes medical necessity for contact lenses?
A diagnosis of Keratoconus, Anisometropia or to correct extreme visual acuity problems uncorrectable with normal spectacle lenses.
   
Who is staying with ACS?
Approximately 200,000 – 300,000 of the individuals covered under the current program.
   
How do you account for dual coverage (members that have Medicaid and Medicare)?
These members will remain in the current system and will not be eligible for the enhanced benefits.
   
How will these claims be filed?
Providers should submit to ACS for payment.
   
Explain the Non - Covered Item Form?
This form is to be utilized anytime an enrollee has an out-of-pocket obligation to your office. It will be used to detail the transaction and will become a permanent part of the patient’s record.
   
Where can the Non - Covered Form be found?
The Non - Covered Services Form is available here and within the Provider Manual.
 
  Materials
   
What types of eyeglass lenses are available for Medicaid recipients?
Standard plastic CR-39 is covered in single vision and flat top bifocal lenses unless prior authorization is obtained from Avesis.
   
What type of frames will be covered?

There are three options. Providers will need to choose a material option.

  1. As a provider, you can supply and maintain an inventory of 35 frames including 20 children's styles, 5 unisex adult styles, 5 men's styles and 5 women's styles. Frames in this selection must carry a minimum 1- year breakage warranty.

  2. The Provider can obtain a "covered frame" kit from the Georgia Department of Corrections (GCI) and place all eyeglass orders with GCI. The provider will be reimbursed a dispensing fee. Glasses should arrive at the ordering provider’s office within three weeks from the date the order is placed with GCI. Providers who select one of the two available frame kits are eligible to receive a $15 dispensing fee.

  3. The Provider can receive a "covered frame" kit from Essilor at no cost to the practice. In turn, all eyeglass orders will be placed directly with Essilor's assigned laboratory. The provider will be reimbursed a dispensing fee. Glasses should arrive at the ordering provider’s office within five business days from the date the order is placed with Essilor. Providers who select one of the two available frame kits are eligible to receive a $15 dispensing fee.
If the member wishes to buy-up outside the covered frame selection, Avesis will reimburse the provider for the frames and lenses up to the allowable amount.
   
Under the buy up option can a provider hold on to the glasses until payment is received?
Yes, if it is your practice policy to do so for all customers.
   
Is there a warranty on frames?
Yes, 1 year warranty against manufacture's defects.
   
Do all of the options have a dispensing fee?
No, only options 2 and 3 have a $15 dispensing fee.
   
Can the provider choose where the eyeglasses are fabricated?
Yes, depending on the material option you select as noted above.
   
Is there a replacement policy for lost glasses?
Lost glasses are not covered and the member is responsible for replacement. Providers who need to re-order lenses due to prescription change must call the Avesis Customer Service Department for instructions on how to proceed.
   
Will I be required to purchase the frame kit should I select Option 2 or Option 3?
Providers who select Option 2 or Option 3 will receive the corresponding frame kit on consignment. Providers will be responsible for maintaining the integrity of those frames. Frames that are lost, damaged or destroyed will be charged to the provider at a rate of $25.00 per frame.
 
  Claims
   
Which claims go to Avesis and which claims go to the CMO?
All services provided by doctors of Optometry to enrollees of the CMO's will be presented to Avesis for adjudication.
   
How are claims for service submitted?
  • Electronic claims can be submitted through WebMD

  • Claims can be submitted electronically by going to the Avesis website
  • A HCFA/CMS-1500 form can be mailed to:

    Avesis Incorporated
    Attn: Vision Claims
    P.O. Box 7777
    Phoenix, Arizona 85011-7777
   
What is the turnaround time for claims to be paid?
All clean claims are processed by Avesis within 15 business days of receipt.
   
How will I be paid?
Providers will receive reimbursement in one of two ways:
  1. Providers utilizing electronic methods for member eligibility and claim submission functions, the provider will be eligible to receive payments from Avesis via Electronic Funds Transfer (EFT).

  2. Avesis issues provider remittance checks twice monthly.
   
What do I do if a claim is returned for correction?
The provider should resubmit a HCFA/CMS-1500 form noted with "CORRECTED CLAIM" at the top of the form and the correct information populated. This should be mailed to Avesis attention "CORRECTED CLAIMS." A claim submitted electronically cannot be resubmitted electronically for correction.
   
How does a provider get reimbursed for services rendered prior to the new contract effective date with the CMO's / Avesis?
For dates of service prior to your regions roll out date, providers should continue to submit claims as they are today to the administrator for the Division of Medical Assistance. Claims should be submitted to Avesis in accordance with the roll out dates of this program outlined here.
   
What codes should I use to bill eye examinations?
When a member presents for their annual eye examination and it is their intent to have the health and visual acuity of their eyes checked and/or prescription for spectacles updated, the professional fees should be billed as:

S0620 - Routine eye examination including refraction: new patient

S0621 - Routine eye examination including refraction: established patient
   
Do Routine Exams or Medical Management require a referral?
There is no referral for a Routine Exam or Medical Management.
   
Do all the CMO's have a $10 co-payment?
No, only WellCare has a $10 co-payment and only on the adult eye examination.
   
What fees should be submitted to Avesis?
Your practices’ usual and customary fees should be submitted when filing your claim with Avesis. Avesis will calculate and reimburse the claims at the prevailing contracted fees.
   
How should non-routine services be billed?
Providers should use their professional judgment to determine the appropriate medical management code for services provided.
   
Can I bill for a routine exam and medical management on the same day?
Yes, where medically necessary and appropriate.
   
How long do I have to file a claim?
The Avesis timely filing guideline is ninety (90) days from the date of service until the date the claim is received by Avesis. We recommend providers follow up on all open claims within thirty (30) days.
   
Does Avesis require a referral for medical management?
No referrals are needed. Avesis will make payments at the prevailing Georgia Medicaid prevailing fee schedule.
   
How much is a vision provider being reimbursed for medical management?
Medical management codes will reimburse at the prevailing Georgia Medicaid fee schedule.
 

 
   
   
 
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