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    J. Sklar Medical Billing SVC provides an optical Medicaid claim form for providers. The form collects information such as the provider ID, patient name and ID, date of service, and codes for examination and vision services rendered. Examination codes include initial and subsequent intermediate exams, comprehensive exams, and follow up exams. Vision codes include single vision lenses with various sphere powers, compound lenses, and bifocals, along with codes for dispensing services and materials like frames, dispensing single vision or bifocal lenses, polycarbonate lenses, and repairs. The form is a PDF version that can be printed two-per-page on carbon copy paper for record keeping.

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    J. Sklar Medical Billing SVC provides an optical Medicaid claim form for providers. The form collects information such as the provider ID, patient name and ID, date of service, and codes for examination and vision services rendered. Examination codes include initial and subsequent intermediate exams, comprehensive exams, and follow up exams. Vision codes include single vision lenses with various sphere powers, compound lenses, and bifocals, along with codes for dispensing services and materials like frames, dispensing single vision or bifocal lenses, polycarbonate lenses, and repairs. The form is a PDF version that can be printed two-per-page on carbon copy paper for record keeping.

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    342 views1 page

    Clickable M

    Uploaded by

    api-240084111
    J. Sklar Medical Billing SVC provides an optical Medicaid claim form for providers. The form collects information such as the provider ID, patient name and ID, date of service, and codes for examination and vision services rendered. Examination codes include initial and subsequent intermediate exams, comprehensive exams, and follow up exams. Vision codes include single vision lenses with various sphere powers, compound lenses, and bifocals, along with codes for dispensing services and materials like frames, dispensing single vision or bifocal lenses, polycarbonate lenses, and repairs. The form is a PDF version that can be printed two-per-page on carbon copy paper for record keeping.

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    © All Rights Reserved
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    J. SKLAR MEDICAL BILLING SVC WWW.JSKLAR.

    COM
    New York MedicAID Claim Form
    • P.O. BOX 340 • Valley Stream, NY 11582 • 516-791-5630 • OPTICALBILLING@GMAIL

    MEDIC-AID PROVIDER # or NPI PROVIDER NAME:


    PATIENT: LAST NAME: COMMENT/ HMO NAME:

    I.D. # - M F YOB :

    Replacement Glasses >> Check If Pt Has: HMO? DATE OF SERVICE


    EXAMINATION CODES: CIRCLE CODES FOR SERVICES RENDERED:
    f1 92002 INTERMED. EXAM - Initial -f1 92012 INTERMED. EXAM - Subsequent (after 2yrs)
    f2 92004 COMPR. EXAM - Initial -f2 92014 COMPR. EXAM - Subsequent (after 2yrs)
    *** af2 99212 FOLLOW UP EXAM Dx. # : -P 92250 FUNDUS PHOTOS
    af3 99213 FOLLOW UP EXAM Dx. # : -I 92225 aI 92226 OPHTHALMOSCOPY - Initial./subs
    af4 99214 FOLLOW UP EXAM Dx. # : f8 92081 af8 92082 VISUAL FIELDS - level 1 / level 2

    SINGLE VISION: SPHERES


    f3 V2100 PL - 4.00 -f7 V2101 4.25 - 7.00 V2102 7.25 - 20.00
    COMPOUNDS
    f4 V2103 PL - 4.00 = PL - 2.00 CYL f6 V2107 4.25 - 7.00 = PL - 2.00 V2111 7.25- 12.00 = PL - 2.00
    f5 V2104 PL - 4.00 = 2.25 - 4.00 V2108 4.25 - 7.00 = 2.25 - 4.00 V2112 7.25- 12.00 = 2.25- 4.00
    BIFOCALS: SPHERES
    -f 3 V2200 PL -4.00 af7 V2201 4.25- 7.00 V2202 7.25- 20.00
    COMPOUNDS
    -f4 V2203 PL -4.00= PL -2.00 -f6 V2207 4.25 - 7.00 = PL - 2.00 V2211 7 25- 12.00 = PL - 2.00
    -f5 V2204 PL- 4.00= 2.25-4.00 V2208 4.25 - 7.00 = 2.25 - 4.00 V2212 7.25- 12.00 = 2.25 - 4.00
    DISPENSING SERVICES AND MATERIALS

    -F V2020 FRAME -D 92340 DISPENSE S.V. -B 92341 DISPENSE BIFOCAL -f10 V2220 ___ ADD > 3.25
    aP S0580 ___ POLYCARB -r 92370 REPAIR OTHER__________________ OTHER__________________ V 417 2017

    MEDICAID CLAIM FORM


    PDF VERSION
    V417
    04/05/2017
    Made wide so that it can be shrunk to fix on 2-part NCR PAPER, / 2 UP PER PAGE

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