ATTACHMENT_A.docx.pdf
PDF 257 KB Posted
- Attached to
- Eye Prosthetic Services for DOC Inmates
- Contract number
- 410008-W21-ELB7746-GEN-03
- Issued by
- Wisconsin
About this file
This document is Attachment A to a contract between the Wisconsin Department of Corrections and Global Prosthetics, located at 6401 Odana Road, Madison, Wisconsin 53719. The contract establishes deliverables and fee schedules for prosthetic eye services provided to the Department of Corrections under the administration of Governor Tony Evers and Secretary Kevin A. Carr.
The contract covers comprehensive ocular prosthetic services including custom ocular prosthesis fabrication, cleaning and polishing, adjustments, enlargements, scleral shells, and custom conformers. Payment is structured at 115% of the Medicare Fee Schedule for procedures covered by Medicare, while non-Medicare procedures are paid at 80% of the provider's billed charges according to a specified fee schedule. Key pricing includes $2,560 for custom ocular prosthesis, $100 for cleaning and polishing, $200 for adjustments, $480 for enlargements, $3,040 for scleral shells, and $320 for custom conformers. The contract specifies maintenance recommendations of cleaning and polishing every six months with full replacement every five years, and includes patient education on prosthetic eye care at each appointment.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 7746_BAA_Global_.pdf | ||
| 7746_Contract_Global.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
WISCONSIN DEPARTMENT OF CORRECTIONS
Governor Tony Evers / Secretary Kevin A. Carr
3099 E. Washington Ave. PO Box 7925 Madison, WI 53707 Phone: (608) 240-5000 doc.wi.gov
ATTACHMENT A
DOC Deliverables
The Provider performs services at office: Global Prosthetics, 6401 Odana Rd, Madison, WI 53719.
It is recommended that the prosthetic eye is cleaned and polished every six months and replaced every five years.
At time of replacement, the patient is seated across from the provider and the new eye is painted to replicate the remaining eye in color.
At each appointment, the provider instructs the patient on care and maintenance of the prosthetic eye.
DOC Fee Schedule
ALL PROCEDURES WILL BE PAID 115% OF THE MEDICARE FEE SCHEDULE. THOSE NOT IDENTIFIED IN
THE MEDICARE FEE SCHEDULE WILL BE PAID 80% OF THE BILLED CHARGE RATE USING THE FEE
SCHEDULE BELOW
DOC Fee Schedule (80% of Fee)
CPT Codes (Procedure Codes - HCPCS )
V 2623 Custom Ocular Prosthesis OD or OS $ 2560.00
V 2624 Clean and Polish $ 100.00
V 2625 Enlargement (Build up) of Prosthesis $ 480.00
V 2626 Adjustment $ 200.00
V 2627 Scleral Shell $ 3040.00
V 2628 Fit and Fabricate Custom Ocular Conformer $ 320.00
V 2629 Miscellaneous Impression under anesthetic $ 160.00
Custom Ocular Prosthetic with peg $ 3040.00
Other potential processes $ Variable
DocuSign Envelope ID: FE1EDD30-C228-489F-BBBB-63422E7E313D
| 2020-08-27T09:19:15-0700 | |
| Digitally verifiable PDF exported from www.docusign.com |
File details come from the government source that posted it. Updated .