Communiqué to Dispensing Opticians and Optometrists
Transcription
Communiqué to Dispensing Opticians and Optometrists
CANADIAN ARMED FORCES Communiqué to Dispensing Opticians and Optometrists Since January 15, 2015, Canadian Armed Forces and eligible foreign military members have the choice to acquire frame(s) and lenses from a provider of choice. This process must be pre-approved on form DND 1615, by a supporting CAF medical clinic prior to members reporting for optical goods and/or services. This pre-authorization form (DND 1615) will be hand carried by CAF members to providers and begins the financial process for each transaction. The form indicates both the specifics of requirements (section 3), such as type and quantity, as well as the benefit codes, with amounts that are based on the member’s prescription. Should the member choose eyeglasses that exceed the prescribed amounts, they will individually be responsible for any additional cost. No modification to the pre-authorized form is to be done by the provider. The member’s prescription will need to be transferred by the provider onto the DND 1615 (section 6) in order to both determine the reimbursable rate and to start the reimbursement process. The papillary distance will also need to be indicated on this form. If the cost invoiced by the provider exceeds what is authorized (i.e. a high index 1.74 prescription is billed to DND at a cost of $575 when the prescription indicates an index of less than -5.75, which should have been billed at $275), the DND 1615 will be returned to the provider who must then adjust the cost according to the approved rate for that specific prescription. No glass lenses are to be issued to military members and transition lenses should not be offered to CAF members as they are not reimbursable. If a member wishes to upgrade to glass lenses or transition, the member is responsible for the entire cost of the frame and lenses. When a safety frame is requested, it must have side shields and meet CSA standards. When the member arrives to pick up his/her glasses, the member must sign and date the DND 1615 (section 7) form indicating that he/she has, indeed, obtained the items as indicated. The provider then indicates the applicable benefit code and cost on this form (section 6), signs section 8 and returns the first 2 copies to the clinic named on the form. Once verified at the CAF clinic, this document will be forwarded to Medavie Blue Cross (by the clinic) for payment. A copy of the DND 1615 form is attached for your information. If you have any questions, please contact the Medavie Blue Cross Provider Inquiry Line toll free at 1-888-261-4033. Administered by Blue Cross on behalf of the Canadian Forces Géré par la Croix Bleue au nom de la Défense nationale DND‐023 04/03 PROTECTED A (When completed) - PROTÉGÉ A (Une fois rempli) Pre-authorization Vision (Eye) Care - Program 14 Pré-autorisation soins de la vue (yeux) - Programme 14 Section 1 Health Care Center Identification / Identification Centre de soins de santé Name - Nom Section 2 Member - Membre Name - Nom Initials - Initiales Address - Adresse Service No. - N° de service Health Card No. - N° de carte de santé Telephone - Téléphone Telephone - Téléphone Rank - Grade Section 3 Authorized Benefits - Bénéfices autorisés Quantity - Quantité Quantity - Quantité Pair of glasses - Paire de lunettes Lenses for respirator glasses - Lentilles pour respirateur Pair of sunglasses with UV and anti-reflective Paire de lunettes de soleil avec UV et antireflets Lenses ballistic - Lentilles balistiques Pair of safety frames - Paire de monture de sécurité Lenses only - Lentilles seulement Computer glasses - Lunettes pour ordinateur Section 4 Health Care Centre Pre-Authorization - Pré-autorisation Centre des soins de santé The above named personnel is pre-authorized to receive the requested frames and/or lenses as per section 3 above with cost according to the criteria (max cost reimbursed) as per Section 5. La personne ci-haut mentionnée est pré-autorisée à recevoir montures et/ou lentilles qu'autorisé selon la section 3 selon les critères (prix max autorisé) de la section 5. Name - Nom Position - Poste Signature Date Section 5 Benefit Codes - Code d'avantage 602260 = $ 275 CR-39 Computer glasses 630010 = $ 275 CR-39 Single or bifocal vision with sphere of -5.75 or less spherical equivalent or sphere of +4.75 or less written in minues (-) cylinder 630015 = $ 375 Progressive lenses with sphere of -5.75 or less spherical equivalent or sphere of +4.75 or less written in minus (-) cylinder 630020 = $ 375 1.6 High index lenses, sphere from -6.00 to -7.75 spherical equivalent or sphere +5.00 to +5.75 written in minus (-) cylinder 630025 = $ 475 1.67 High index lenses, sphere from -8.00 to -9.75 spherical equivalent or sphere +6.00 to +7.75 written in minus (-) cylinder 630030 = $ 575 1.74 High index lenses, sphere over -10.00 spherical equivalent or +8.00 written in minus (-) cylinder 602260 = 275 $ CR-39 Lunettes pour ordinateur 630010 = 275 $ CR-39 Simple ou vision bifocal, sphère de -5.75 ou moins équivalent sphérique ou sphère de +4.75 ou moin écrit en cylindre négatif. 630035 = $ 375 Pair of sunglasses 630035 = 375 $ Paire de lunettes de soleil 630040 = $ 275 Pair of safety frames with safety lenses 630040 = 275 $ Paire de monture de sécurité avec lentilles de sécurité 604148 = $ 125 CR-39 Lenses for respirator glasses 604148 = 125 $ CR-39 Lentilles pour masque à gaz 602100 = $ 125 Lenses for ballistic in polycarbonate 630045 = Lenses only (When lenses only are requested, the amount is proportional to the prescription under the above benefit codes minus $150) 602100 = 125 $ Lentilles pour les balistiques en polycarbonate 630045 = Lentilles uniquement (Lorsque seules des lentilles sont requises, le montant est proportionnel à l'ordonnance en vertu des codes d'avantages ci-haute moins 150$) 630015 = 375 $ Lentilles progressives avec sphère de -5.75 ou moins équivalent sphérique ou sphère de +4.75 ou moin écrit en cylindre négatif 630020 = 375 $ 1.6 Lentilles haut indices, sphère de -6.00 à -7.75 équivalent sphérique ou sphere de +5.00 à +5.75 écrit en cylindre négatif 630025 = 475 $ 1.67 Lentilles haut indices, sphère de -8.00 à -9.75 équivalent sphérique ou sphère de +6.00 à +7.75 écrit en cylindre négatif 630030 = 575 $ 1.74 Lentilles haut indices, sphère plus haute de -10.00 équivalent sphérique ou sphère plus haute de +8.00 écrit en cylindre négatif Section 6 Sph Cyl Axis-Axe Add Prism(e) Base PD-DI Applicable Benefit Code(s)from above chart Code(s) d'avantage applicable selon le tableau ci-haute Code Cost - Coût O.D. O.S. Section 7 Member's Signature - Signature du membre I, the member, hereby certify that the above benefits have been rendered. - Moi, le militaire, atteste par la présente que les avantages ci-dessus ont été rendus. Name - Nom Signature Date Section 8 Provider's Name - Nom du fournisseur Address - Adresse Telephone - Téléphone FHCPS Provider's No. - N° du fournisseur SFTDSS I, the Health Care Provider named above agree to return to the required health information to the appropriate address listed in Appendix 1 of the Provider Information Kit and that rate charges will be in accordances with criteria under Benefit Codes. Moi, le fournisseur de soins de santé nommé ci-haut, consens à retourner les renseignements sur la santé requis à l'adresse pertinente figurant à l'annexe 1 de la trousse à l'intention des fournisseurs et que le prix de la facture sera en conformité selon les critères des codes d'avantage. Signature Date Section 9 Recommended for Payment - Recommandé pour paiement Certified pursuant to Section 34 of the Financial Administration Act - Certifié conformément à l'article de la Lois sur la gestion des finances publiques Name - Nom DND 1615 (12-2014) 7530-21-908-1638 Design: Forms Management 613-995-9944 Conception : Gestion des formulaires 613-947-8944 Position - Poste Signature COPY 1 - THIRD PARTY CLAIMS ADMINISTRATOR COPIE 1 - ADMINISTRATEUR DE LA REVENDICATION D'UN TIERS PROTECTED A (When completed) - PROTÉGÉ A (Une fois rempli) Date