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