Vision Care and Eyewear Manual (2025)

1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.1a. Insured's ID NumberRequiredEnter the member's seven-digit Health First Colorado ID number as it appears on the Health First Colorado identification card.
Example: A123456.2. Patient's NameRequiredEnter the member's last name, first name, and middle initial.3. Patient's Date of Birth/SexRequiredEnter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.

4. Insured's NameConditionalComplete if the member is covered by a Medicare health insurance policy.
Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.5. Patient's AddressNot Required6. Client Relationship to InsuredConditionalComplete if the member is covered by a commercial health care insurance policy.7. Insured's AddressNot Required8. Reserved for NUCC UseNot Required9. Other Insured's NameConditionalIf field 11d is marked "YES", enter the insured's last name, first name and middle initial.9a. Other Insured's Policy or Group NumberConditionalIf field 11d is marked "YES", enter the policy or group number.9b. Reserved for NUCC Use9c. Reserved for NUCC Use9d. Insurance Plan or Program NameConditionalIf field 11d is marked "YES", enter the insurance plan or program name.10a-c. Is patient's condition related to?ConditionalWhen appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.10d. Reserved for Local Use11. Insured's Policy, Group or FECA NumberConditionalComplete if the member is covered by a Medicare health insurance policy.
Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.11a. Insured's Date of Birth, SexConditionalComplete if the member is covered by a Medicare health insurance policy.
Enter the insured's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070118 for July 1, 2018.
Place an "X" in the appropriate box to indicate the sex of the insured.11b. Other Claim IDNot Required11c. Insurance Plan Name or Program NameNot Required11d. Is there another Health Benefit Plan?ConditionalWhen appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.12. Patient's or Authorized Person's signatureRequiredEnter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.

13. Insured's or Authorized Person's SignatureNot Required14. Date of Current Illness Injury or PregnancyNot RequiredComplete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness

15. Other DateNot Required16. Date Patient Unable to Work in Current OccupationNot Required17. Name of Referring PhysicianConditional18. Hospitalization Dates Related to Current ServiceConditionalComplete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date, and two digits for the year. Example: 070118 for July 1, 2018. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.19. Additional Claim InformationConditional20. Outside Lab?
$ ChargesConditionalComplete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.

21. Diagnosis or Nature of Illness or InjuryRequiredEnter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.

22. Medicaid Resubmission CodeConditionalList the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.

23. Prior AuthorizationConditionalEnter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.24. Claim Line DetailInformationThe paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).

24A. Dates of ServiceRequired

The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010124 for January 1, 2024.

From			To
01	01	24

or

From			To
01	01	24	01	01	24

Span dates of service

From			To
01	01	24	01	31	24

24B. Place of ServiceRequired

Enter the Place of Service (POS) code that describes the location where services were rendered. The Health First Colorado accepts the CMS place of service codes.

03	School
04	Homeless Shelter
11	Office
12	Home
15	Mobile Unit
20	Urgent Care Facility
21	Inpatient Hospital
22	Outpatient Hospital
23	Emergency Room Hospital
25	Birthing Center
26	Military Treatment Center
31	Skilled Nursing Facility
32	Nursing Facility
33	Custodial Care Facility
34	Hospice
41	Transportation - Land
51	Inpatient Psychiatric Facility
52	Psychiatric Facility Partial Hospitalization
53	Community Mental Health Center
54	Intermediate Care Facility - MR
60	Mass Immunization Center
61	Comprehensive IP Rehab Facility
62	Comprehensive OP Rehab Facility
65	End Stage Renal Dialysis Trtmt Facility
71	State-Local Public Health Clinic
99	Other Unlisted

24C. EMGConditionalEnter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.

24D. Procedures, Services, or SuppliesRequiredEnter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.

24D. ModifierConditionalEnter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

24Unrelated Evaluation/Management (E/M) service by the same physician during a postoperative period
Use with E/M codes to report unrelated services by the same physician during the postoperative period. Claim diagnosis code(s) must identify a condition unrelated to the surgical procedure.

26Professional component
Use with diagnostic codes to report professional component services (reading and interpretation) billed separately from technical component services.
Report separate professional and technical component services only if different providers perform the professional and technical portions of the procedure.
Read CPT descriptors carefully. Do not use modifiers if the descriptor specifies professional or technical components.

51Multiple Procedures
Use to identify additional procedures that are performed on the same day or at the same session by the same provider. Do not use to designate "add-on" codes.

55Postoperative Management only Surgery related eyewear
Use with eyewear codes (lenses, lens dispensing, frames, etc.) to identify eyewear provided after eye surgery. Benefit for eyewear, including contact lenses, for members over age 20 must be related to surgery. Modifier -55 takes the place of the required claim comment that identifies the type and date of eye surgery. The provider must retain and, upon request, furnish records that identify the type and date of surgery.

59Distinct Procedural Service
Use to indicate a service that is distinct or independent from other services that are performed on the same day. These services are not usually reported together but are appropriate under the circumstances. This may represent a different session or member encounter, different procedure or surgery, different site or organ system or separate lesion or injury.

62Two surgeons
Use when two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons

76Repeat procedure or service by the same physician/provider/other qualified health care professional
Use to identify subsequent occurrences of the same service on the same day by the same provider. Not valid with E/M codes.

77Repeat procedure by another physician/provider/other qualified health care professional
Use to identify subsequent occurrences of the same service on the same day by different rendering providers.

79Unrelated procedure or service by the same surgeon during the postoperative period
Unrelated procedures or services (other than E/M services) by the surgeon during the postoperative period. Use to identify unrelated services by the operating surgeon during the postoperative period. Claim diagnosis code(s) must identify a condition unrelated to the surgical procedure.

80Assistant surgeon
Use with surgical procedure codes to identify assistant surgeon services. Note: Assistant surgeon services by non-physician practitioners, physician assistants, perfusionists, etc. are not reimbursable.

GYItem or services statutorily excluded or does not meet the Medicare benefit.
Use with podiatric procedure codes to identify routine, non-Medicare covered podiatric foot care. Modifier -GY takes the place of the required provider certification that the services are not covered by Medicare. The Medicare non-covered services field on the claim record must also be completed.

KXSpecific required documentation on file
Use with laboratory codes to certify that the laboratory's equipment is not functioning or the laboratory is not certified to perform the ordered test. The -KX modifier takes the place of the provider's certification, "I certify that the necessary laboratory equipment was not functioning to perform the requested test", or "I certify that this laboratory is not certified to perform the requested test."

24E. Diagnosis PointerRequiredEnter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.

24F. $ ChargesRequiredEnter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co-pay or commercial insurance payments from the usual and customary charges.

24G. Days or UnitsRequiredEnter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.

24G. Days or UnitsGeneral InstructionsA unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.

Lens materials
One lens equals one unit of service. If two lenses of the same strength are provided, complete one billing claim line, entering two units of service and the total charge for both lenses. Lenses of different strengths are billed on separate claim lines.

Lens dispensing
A dispensing fee is allowed for each lens. For two lenses, complete on claim line with two units of service and charge for both lenses.

24H. EPSDT/Family PlanConditional

EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:

AV	Available- Not Used
S2	Under Treatment
ST	New Service Requested NU Not Used

Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom, unshaded area of the field.

24I. ID QualifierNot Required24J. Rendering Provider ID #RequiredIn the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.25. Federal Tax ID NumberNot Required26. Patient's Account NumberOptionalEnter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).27. Accept Assignment?RequiredThe accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.28. Total ChargeRequiredEnter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.29. Amount PaidConditionalEnter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

30. Rsvd for NUCC Use31. Signature of Physician or Supplier Including Degrees or CredentialsRequiredEach claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #RequiredEnter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.33. Billing Provider
Info & Ph #RequiredEnter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code33a- NPI NumberRequired33b- Other ID #If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.