MedicaidBilling CodesHigh impact
BT2026114: IHCP clarifies FQHC and RHC billing procedures for vision services
Indiana Medicaid (IHCP)·IN · Ophthalmology, Optometry, Family Medicine +1 more·Reimbursement
Effective date
Jul 2, 2026
We identified it
Jul 3, 2026
Summary
IHCP clarifies billing procedures for vision services at FQHCs and RHCs, requiring all vision services to be billed on professional claims with HCPCS code T1015 and a valid encounter code. When eyeglasses are picked up on a separate date from the eye exam, providers have two options: submit one combined claim (eligible for PPS rate) or submit separate claims for exam and materials (materials-only claim must be denied). Materials are limited to basic frames and lenses; upgrades and non-medically-necessary contact lenses are member responsibility with advance notification required.
Action Required
Effective immediately (July 2, 2026): 1) Billing team must update billing system and provider training to ensure all vision service claims for FQHC/RHC encounters include HCPCS code T1015 plus a valid encounter code from the Myers and Stauffer FQHC-RHC Valid Encounter Code Listing. 2) Update claim submission workflows to route vision claims to Gainwell Technologies (for FFS members) or appropriate MCO (for managed care members) as medical claims, not separate vision claims. 3) For split billing scenarios: Train staff that materials-only claims MUST include T1015 and applicable eyewear procedure codes, then must be denied with EOB code 4124 (not a valid encounter code) because materials are included in the PPS rate of the exam claim. 4) Update member consent/waiver processes to document advance notification of noncoverage for eyewear upgrades, transitional lenses, second pairs, sunglasses, and non-medically-necessary contact lenses before member assumes financial responsibility. 5) Establish documentation requirements confirming that optician services are only billed when performed in conjunction with a valid face-to-face encounter with a qualifying practitioner. Failure to include T1015 and valid encounter codes will result in claim denials and ineligibility for PPS rate reimbursement.