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Pre-authorisation of Adult GOS 4 claims

National Briefing

Under GOS (General Ophthalmic Services) Regulations (Optical Payments and Charges Regulations 2013) children and adult patients who qualify for GOS can receive a repair or replacement voucher (GOS4) if they lose or damage their glasses. Children qualify for unlimited repair and replacements, but adults only qualify if a health condition has led to the loss or breakage of the glasses, i.e., arthritis. Under current regulation, all adult claims must be approved by NHSBSA prior to the service being provided to the patient.

NHS Business Services Authority (NHSBSA) introduced a standardised and robust approach on behalf of NHS England to run the pre-authorisation of adult GOS 4 vouchers. This service began in November 2018. The process for pre-authorising GOS 4s for adults will be as follows:

          1. Patient aged over 16 goes to GOS contractor and asks for repair or replacement
          2. GOS contractor downloads and completes the GOS 4 Pre authorisation template and emails it to NHSBSA at paos@nhs.net, core hours of working are 08:00am – 16:30pm Monday to Friday. (Telephone service has been paused due to Covid-19).
          3. NHSBSA Caseworker reviews the claim against a standardised list of conditions. Alternatively they will escalate to a clinical advisor if the circumstances are not covered by the list. Please note if the spectacles have been made up before seeking pre authorisation from NHSBSA the claim will result in being rejected.
          4. If the request is not approved the caseworker will provide the contractor with a reason and log the details of the claim.
          5. If the request is approved the contractor will be issued with a unique code. The contractor should then write this code on the GOS 4 form and submit to PCSE for payment.
          6. PCSE will check the form during processing. If the patient is over 16 and there is no code on the form, they will reject the payment. If there is a code included PCSE will process the payment.
          7. NHSBSA will then check GOS 4 submissions as part of post payment verification. Any claims that have been submitted inappropriately (i.e. with missing or incorrect codes) will be recovered via the PPV process.