Reimbursement Requirements for Vision Correction Materials

February 2019

WSI reimburses for vision correction materials (e.g. eyeglasses, contact lenses) when prescribed and deemed appropriate for an accepted workers compensation claim. The following are circumstances under which WSI may reimburse for vision correction materials:

  • A work injury causes damage to existing vision correction materials requiring replacement
  • Vision correction materials become necessary to correct an impairment caused by a work injury
  • Replacement vision correction materials are necessary to continue the correction of an impairment caused by a work injury

A provider must obtain prior authorization prior to dispensing vision correction materials. The request for approval must include all add-on features, whether optional or prescribed.  To request prior authorization, a provider may contact the claims adjuster by calling WSI’s Customer Service Department at 701-328-3800 or 800-777-5033.

Reimbursement for vision correction materials is issued per the WSI Fee Schedule. When a work injury causes damage to existing vision materials, WSI may issue a one-time reimbursement in full to replace the exact features present prior to the damage. A provider may not bill the patient, employer, or another insurer for the balance of a paid or denied charge.

For cosmetic or functional features not necessary to treat a work injury, a provider may utilize the Advanced Beneficiary Notice (ABN) form. The ABN form should provide the estimated costs for each elective feature and allows an injured worker to accept financial responsibility. When a signed ABN form is in place, a provider should append modifier -GA to the applicable line item(s) and attach the ABN form to the medical bill.

WSI requires a provider submit charges for vision correction materials with the applicable HCPCS codes on a CMS-1500 form or via EDI. Charges submitted to WSI on an invoice are not eligible for reimbursement. For complete information on WSI’s billing options, a provider should visit the Billing/Payment section of the WSI website.

If you have questions about this article, please send an email to wsipr@nd.gov.  To receive provider news, subscribe to our Email Updates list.