Form 6499, Application for Treatment

Instructions

Updated: 3/2017

Purpose

Form 6499 is used to provide information needed to determine an applicant's eligibility for Blindness Education, Screening and Treatment (BEST) services. To be eligible, an individual must be an adult resident of the state of Texas who:

• has been referred to the program by the individual's treating physician or optometrist;
• has certified to the physician or optometrist that the individual does not have health insurance or other available resources with which to pay for prescribed treatment to prevent blindness; and
• has been certified by the physician or optometrist as having a medically urgent eye condition that poses an imminent risk of permanent and significant visual loss if not treated with surgery or medical intervention.  Medically urgent eye conditions include glaucoma, diabetic retinopathy and detached retina. Other eye conditions must be determined to be medically urgent by both the applicant's physician and the ophthalmologic consultant or designee.

Program Information

The BEST program is funded with voluntary donations and funds may not be available at the time an individual is referred for assistance. If an eligible individual is denied services by the program based on the inadequacy of donations to cover the cost of services, the physician may request that the individual be placed on a waiting list pending receipt of adequate funds. During the waiting period, BEST program staff will attempt to refer waiting applicants to other available treatment resources. Individuals on the waiting list shall be served in order by referral date and time.

The BEST program does not cover over-the-counter and/or nonprescription drugs. BEST will only pay for ophthalmic prescription drugs needed to prevent blindness. Payment for the cost of covered prescription drugs is limited to the number of refills prescribed by the treating physician or optometrist, or one year, whichever is less. The BEST program will not pay for a name-brand drug if a generic alternative is available.

The BEST program does not pay for routine eye examinations that are unrelated to requested medical treatment. However, BEST will pay for diagnostics and testing that are submitted with a treatment request. An application for diagnostics only must be made on behalf of an applicant with 20/25 vision or worse in the better eye with best correction, or for an applicant who the treating physician suspects may need treatment. Follow-up eye examinations covered by a global treatment period are the responsibility of the treating physician.

Procedure

Form 6499 contains the most common procedures, codes and costs to calculate the requested medical treatment(s). Blank fields are provided to enter a procedure code that is not listed on the form. Contact the Regional Program Support manager in your local area to obtain the correct fee for the unlisted procedure. The total cost for each provider should be included in the respective billing information section. Form 6499 must be completed with the applicant's physician. Only fully completed and signed applications will be processed and the form must be legibly printed or typed.

Mail or fax all completed applications. For assistance or to request information about the nearest office in your area, call the HHSC Office of the Ombudsman at 1-877-787-8999, select a language, and then select Option 3.

Only claims for services approved in advance will be paid. Payment claims for BEST services must be received within 90 days from the date of each service. Claims lacking the information necessary for processing shall be denied as incomplete claims. The program must receive the resubmission of the corrected claim within 60 days from the last denial date or payment will be declined. The BEST program does not pay cancellation charges, charges for missed appointments, consultation fees, or any other charge incurred other than for the actual provision of treatment services.