Optometric and Eyeglass Services

Updated: October 2026

Purpose

ND Medicaid covers optometric and eyeglass services.

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medi caid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

Optometric and Eyeglass services can be provided by the following enrolled providers as allowed by their scope of their licensure: 

• Ophthalmologist;
• Optometrist; or
• Optician.

Providers seeking approval for optometric and eyeglass services requiring service authorization must submit a Request for Service Authorization for Vision Services (SFN 292).

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories. 

Retroactive Eligibility

ND Medicaid does not cover eyeglasses for members who become eligible for Medicaid retroactively when the eyeglasses were purchased before retroactive eligibility was determined. However, eye exams are covered for members who become eligible retroactively. For example, a member had an eye exam and ordered eyeglasses on July 15. On September 1, the member was determined eligible for Medicaid retroactive to July 1. ND Medicaid would cover the eye exam, but not the eyeglasses.

Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

• The provider must be enrolled in ND Medicaid;
• Services must be medically necessary;
• The member must be eligible on the date of service; and
• If applicable, the service has an approved service authorization. 

The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid along with code specific details such as ORP requirements, Service Authorization requirements, and current rates. 

Eye Exams

Members ages 21 and older are limited to one eye examination and refraction every two years. Members ages 20 and under are limited to one eye examination and refraction every 365 days. If an exam or refraction is needed sooner, a service authorization is required. The submission of retroactive authorizations must include good cause to support the service rendered prior to securing a service authorization. Retroactive authorizations are considered on a case-by-case basis. 

Eyeglasses

Members ages 21 and older are eligible for eyeglasses every two years. Members ages 20 and under are eligible for eyeglasses every 365 days. See the Replacement Lenses and Frame section for information regarding replacement glasses.

If the member has a diagnosed medical condition that prohibits the use of the pair of eyeglasses that has been dispensed to the member, an exception may be made allowing eyeglasses to be dispensed outside of the limit requirement. Providers are required to submit a service authorization request and document the member's inability to use the eyeglasses that have been dispensed. 

Frame Services

ND Medicaid will only cover lenses and frames purchased through ND Medicaid's eyeglasses contractor. The eyeglasses contractor must secure an order (prescription) from the ordering practitioner and include the National Provider Identifier NPI, taxonomy and name of the ordering practitioner on the claim to ND Medicaid. The eyeglasses contractor will provide a list of Medicaid covered frames to dispensing providers. Providers must secure a prior authorization for members who require a specialty “deluxe” frame except for flexible frames for members through age five. For members age six and older, a service authorization is required for flexible frames. The Medicaid eyeglasses contractor will provide a list of specialty “deluxe” frames for selection.

Members have the option of using their “existing frames” and ND Medicaid will cover lenses. The existing frame is a frame that the member owns or purchases. When a member chooses to use an existing frame, the following applies:

• Dispensing providers will evaluate existing frames to ensure lenses can be inserted.
• The eyeglasses contractor will decide if the existing frame can be used for Medicaid covered lenses. If the existing frame cannot be used, the eyeglasses contractor will inform the dispensing provider.
• If the existing frame breaks (after lenses are dispensed to the member), ND Medicaid will pay for a frame covered under the eyeglasses contract, but not new lenses. The member can choose to pay privately for new lenses or choose a contract frame that the lenses will fit. 

Lens Styles and Materials

All lenses fabricated by the eyeglasses contractor for members must be in the edged form, edged to shape and size for a specific frame and returned to the dispensing provider as “lenses only,” or edged and mounted into a specific frame and returned to the dispensing provider as “complete Rx order.” Orders for “uncut” lenses are not accepted.

ND Medicaid covers the following lens styles:

• Single vision;
• Flattop segments 28;
• Round 22;
• Flattop trifocals 7 x 28; and
• Executive style bifocals.

ND Medicaid covers the following lens materials:

• Glass;
• CR-39;
• Polycarbonates; and
• High Index (must be medically necessary and requires a service authorization).

Lens Add-ons

Covered for Children (Ages 20 and under) and Adults (ages 21 and older)

• Polycarbonate lenses (Single vision, Bifocal, or Trifocal lenses);
• Tints Rose 1 and Rose 2 (applicable to CR-39 and Polycarbonate lenses only);
• If medically necessary with a service authorization:
  • Blue blocking lenses;
  • Photochromic – plastic (i.e. transition);
  • Photochromic – glass (i.e. photo gray, photo brown);
  • Progressive;
  • Tints other than Rose 1 and Rose 2 (applicable to CR-39 and Polycarbonate lenses only);
  • Ultraviolet; and
  • Slab-off and Fresnel prism.

Any lens style, lens material, tint, coating lens enhancement (polished edge, etc.) not specifically noted above or within this policy will be billed to the dispensing provider at the eyeglasses contractor’s normal and customary charges.

Repair and Refitting

Services involving repair and refitting require service authorization.

Replacement Lenses and Frames

All frames provided by the eyeglass contractor carry a 12-month manufacturer warranty on replacement fronts and temples. Members must take their broken frames to the dispensing provider for the eyeglasses contractor to repair. No new frame style or color can replace the broken frame.

If an adult (age 21 and older) loses or breaks their eyeglasses within the 2-year replacement timeframe, ND Medicaid will not cover another pair.

Glasses will not be covered when lost or broken in a long-term care facility. If the recipient is under full care of the facility due to physical or mental conditions, the facility is responsible for the cost of replacement. The member, caregiver, or family member may not be billed for lost or broken glasses in the long-term care facility. 

If a child (age 20 and under) loses or breaks the first pair of eyeglasses, and the damage is not covered by the warranty, ND Medicaid will replace one pair of eyeglasses within the 365-day replacement timeframe. All replacement requests require a service authorization.

Glasses stolen or destroyed by unnatural means (i.e., fire, flood, motor vehicle accident, natural disaster, domestic dispute) require a service authorization sent with documentation to support the event.

Ordering Eyeglasses

Providers must order eyeglasses from the designated eyeglass contractor, Classic Optical.

Dispensing Services

Ophthalmologists, optometrists, and opticians may provide dispensing services.

Contact Lenses

Contact lenses and applicable dispensing fees require service authorization and are covered only when medically necessary and not for cosmetic reasons. The same limits that apply to eyeglasses and repairs also apply to contacts. Contact lenses are not provided by the eyeglass contractor and therefore may be provided by other providers. When billing for services after prior approval has been obtained, the claim must be submitted with an invoice. The provider dispensing the contact lenses must secure an order (prescription) from the ordering practitioner and include the NPI and taxonomy of the ordering practitioner on the claim to ND Medicaid.

ND Medicaid covers contact lenses when the member has one of the following conditions:

• Keratoconus;
• Sight that cannot be corrected to 20/40 with eyeglasses;
• Aphakia; or
• Anisometropia of 2 diopters or more.

Covered Services for Members with Limited Medicaid Coverage

Medicaid generally does not cover eye exams or eyeglasses for members with Qualified Medicare Beneficiary (QMB) coverage. Always check member eligibility before providing services. ND Medicaid may cover eye exams under the following conditions:

• Following cataract surgery – members who have QMB-only coverage are only eligible for eyeglasses following cataract surgery when Medicare approves the eyeglasses claim. ND Medicaid considers the Medicare coinsurance and deductible for this claim.
• Diabetic diagnosis – members with basic Medicaid coverage, not QMB, who have a diabetic diagnosis. Eyeglasses are not covered for these members.
• Medically Necessary Eye Examinations – eye exams for members with basic Medicaid coverage, not QMB, who have certain eye conditions. Eyeglasses are not covered for these members.

Service Authorization Requirements

A Request for Service Authorization for Vision Services (SFN 292) must be completed in its entirety. The form must include the date of the previous exam, lens, and frame. The present and new Rx is required to include visual acuities. An explanation for medical necessity is required. All requested materials for the glasses must be present on the prior authorization.

Amendments to prior authorizations require a new SFN 292 form be faxed to NDHHS with the amendment noted on the form. 

Providers must follow the Service Authorization Provider Policy.

Noncovered Services

General Noncovered Services

The Noncovered Services Policy contains a general list of services that are not covered by North Dakota Medicaid.

Noncovered services include:

• Dispensing fees for a member who is not eligible for lenses and/or frames within the two (2) year time period for adults, one (1) year for children.
• Services that the provider did not personally provide.  The main exception is that the dispensing service may be performed by the provider’s employee when it is allowed by law.

Documentation Requirements

General Requirements

Providers must keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Records must be retained for at least 7 years after the last date the claim was paid or denied. Providers must follow the documentation requirements in the Provider Requirements Policy. 

Reimbursement Methodology and Claim Instructions

Timely Filing

ND Medicaid must receive an original Medicaid primary claim within one hundred eighty (180) days from the date of service. The time limit may be waived or extended by ND Medicaid in certain circumstances. The Timely Filing Policy contains additional information.

Third-Party Liability

Medicaid members may have one or more additional source of coverage for health services. ND Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources. The Third Party Liability Policy contains additional information.

Client Share (Recipient Liability)

Client share (recipient liability) is the monthly amount a member must pay toward the cost of medical services before the Medicaid program will pay for services received. The Client Share Policy contains additional information. 

Reimbursement

A claim for services must be submitted at the provider’s usual and customary charge. Payment for services is limited to the lesser of the provider’s usual and customary charge or the ND Medicaid calculated reimbursement. 

Claim Form

Optometric and eyeglass services must be billed using the CMS 1500 claim form or 837p. Detailed claim instructions are available on the ND Medicaid Provider Guidelines, Policies & Manual webpage.

Claim Requirements

Claims submitted for materials must include the ordering provider on the claim form.

For electronic claims, reference the table below and the ND Companion Guide 837P. 

For paper claims, box 17 is the name of the ORP provider; 17b is the NPI of the ORP provider. Qualifier DK is required in box 17 to identify if the provider is the ordering provider.

Web portal claims instructions that include an ORP provider are on page 15 of ND MMIS Web Portal Professional Claim Form Submission Instructions.

References

• North Dakota Administrative Code
• North Dakota Century Code
• Code of Federal Regulations

Frequently Asked Questions

Question (Q): May I accept Medicaid payment but bill the patient the difference for upgrades to glasses? 
Answer (A): Medicaid payment is payment in full.

Q: The frame selected by my patient is not supplied by Classic Optical. May I send my order to a lab other than Classic Optical? 
A: No. Providers must order eyeglasses through Medicaid’s contracted eyeglass contractor, Classic Optical.

Contact

600 East Boulevard Ave 
Bismarck, ND 58505-0250
Phone: (701) 328-2310
Email: dhsmedicalservices@nd.gov

Policy Updates

April 2026

• Formatting changes made throughout the policy.

Juily 2026

• ADA updates made throughout the policy. 

October 2026

• Updated SA requirements for flexible frames. An SA is no longer needed for members under age 6.