Hearing Aid Dispensing and Repairs

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1 bmchp.org wellsense.org Reimbursement Policy Hearing Aid Dispensing and Repairs Policy Number: Version Number: 10 Version Effective Date:.07/01/2015 Product Applicability All Plan Products Well Sense Health Plan New Hampshire Medicaid NH Health Protection Program Boston Medical Center HealthNet Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Note: Disclaimer and audit information is located at the end of this document. Policy Summary The Plan will reimburse covered hearing aids, related batteries and accessories based on the provider s contractual rates with the Plan and the terms of reimbursement identified within this policy. This policy does not apply to durable medical equipment (DME) when items are dispensed and billed by a DMEPOS provider. This service is managed by Northwood, Inc. Providers may contact Northwood at or by phone at Prior Authorization Please refer to the Plan s Prior Authorization Requirements Matrix at 1 of 10

2 Definitions Hearing aid - a wearable aid or device designed for or offered for the purpose of aiding or compensating for hearing loss. Provider Reimbursement Hearing Aid Dispensing Requirements An audiologist or hearing aid specialist may dispense a hearing aid only after receiving the following documentation. A complete audiological evaluation (no more than six months before the dispensing of the hearing aid) which consists of: o The date of the evaluation o A written summary of findings and impressions o Recommendation of hearing aid make and model o Monaural or binaural amplification Medical Clearance which indicates the member is a candidate for and has no medical conditions that would contraindicate the use of a hearing aid and that a medical examination was performed no more than six months before the dispensing date of the hearing aid. Hearing Aids Payment for the purchase of a hearing aid includes the following: The hearing aid and standard accessories and options required for proper operation The proper fitting and instruction in the use, care and maintenance The initial one-year manufacturer s warranty against loss or damage The loan of a hearing aid to the member, when necessary MassHealth members: One hearing aid is allowed per ear, per member in a 60-month period without authorization. Lost or damaged hearing aids will require prior authorization. Two monaural fittings dispensed within a six-month period, with one aid dispensed for each ear, are defined as a single binaural fitting Health Plan/ConnectorCare/ Employer Choice Direct Members: The hearing aid benefit is limited to members 21 years old or younger and reimbursement is limited to $2,000 per hearing aid, every 36 months. 2 of 10

3 Major Repairs Includes repair to a hearing aid made at a repair facility and is limited to the following: All warranties and insurance have expired Sent directly to the repair facility or manufacturer that will perform the repair (intermediary handling charges are not reimbursed) The repair service must include a written warranty against all defects for a minimum of six months Major repairs are reported using HCPCS code V5014 and the applicable invoice documentation. The plan will reimburse for the cost of postage and insurance when repairs are covered under an extended warranty. Postage and insurance are reported using HCPCS code V5299, attach the associated invoice documentation. Minor Repairs Includes, but not limited to, the replacement or cleaning of tubing, minor adjustments to assure proper fit, minor office repairs,hearing aid cleaning or replacement parts (tubing, hooks, batter doors, recasing) Hearing aid providers must bill minor repairs using CPT (no documentation is required). This code is not to be reported in conjunction with an office visit E&M and should not be reported separately. Refitting Services Refitting services are reported with HCPCS code V5011. Services must be performed face-to-face and include: Refitting of the aid Orientation Counseling with the member or member s family Contact with interpreters Fitting of a loaner aid, and similar services For MassHealth members, refitting and any related services are only reimbursed if the hearing aid was dispensed more than 1 year prior to the date of service for the refitting. Earmolds Ear molds are reported using HCPCS code V5264 or V5265. Reimbursement for earmolds includes: The ear impression The proper fitting of the earmold Any adjustments needed during the operational life of the earmold 3 of 10

4 When an earmold is included in the manufacturer s price of the hearing aid or the member already has an appropriate earmold it should not be billed to the Plan. Ear Impressions Reimbursement for ear impressions includes one properly formed ear impression for each in-the-ear (ITE) or behind-the-ear (BTE) hearing aid. Ear impressions are reported using HCPCS code V5275. Batteries Batteries are reimbursed for MassHealth, and Care Plus members only. Reimbursement for batteries includes new and unused batteries at the time of purchase. Batteries are reported using HCPCS code V5266. Accessories Accessories include essential items or options for use in the repair or modification of a hearing aid. Accessories are reported using the appropriate HCPCS code. To report items not identified by a specific code, report using V5267 and submit the applicable invoice documentation. Outpatient Hospital Payment for Hearing Aids and Dispensing Outpatient hospitals paid based on an episodic rate will be paid separately for hearing aids and hearing aid dispensing services, subject to the terms of this policy. Service Limitations The Plan does not pay for any of the following services: The rental of hearing aids Personal FM systems, Bluetooth Assistive technology devices provided under federal regulations 34 CFR MassHealth members only: Hearing aids that are completely in the ear canal (CIC) are not reimbursed. Health Plan/ConnectorCare/Employer Choice Direct Members only: The hearing aid benefit is limited to members 21 years old or younger and reimbursement is limited to $2,000 per hearing aid, every 36 months. Applicable Coding and Billing Guidelines Applicable coding is listed below, subject to codes being active on the date of service. Because the American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and the U.S. Department of Health and Human Services may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes may not be all inclusive. These codes are not intended to be used for coverage determinations. 4 of 10

5 Modifiers Certain items require a modifier for proper payment. Failure to submit the appropriate modifier may result in a denial. Monaural hearing aids and dispensing require the submission of modifiers RT or LT. CPT/HCPCS Codes Description Hearing aid examination and selection; monaural Hearing aid examination and selection; binaural Hearing aid check; monaural Hearing aid check; binaural Electroacoustic evaluation for hearing aid; monaural Electroacoustic evaluation for hearing aid; binuaral V5010 Assessment for hearing aid V5011 Fitting/orientation/checking of hearing aid V5014 Repair/modification of a hearing aid V5020 V5030 V5040 V5050 V5060 V5070 V5080 V5090 V5095 V5100 V5110 V5130 V5140 V5150 V5160 V5170 V5180 V5190 V5200 V5210 Conformity Evaluation Hearing aid, monaural, body worn, air conduction Hearing aid, monaural, body worn, bone conduction Hearing aid, monaural, in the ear Hearing aid, monaural, behind the ear Glasses, air conduction Glasses, bone conduction Dispensing fee, unspecified hearing aid Semi-implantable middle ear hearing prosthesis Hearing aid, bilateral, body worn Dispensing fee, bilateral Binaural, in the ear Binaural, behind the ear Binaural, glasses Dispensing fee, binaural Hearing aid, CROS, in the ear Hearing aid, CROS, behind the ear Hearing aid, CROS, glasses Dispensing fee, CROS Hearing aid, BICROS, in the ear Comments Choice Direct Choice Direct 5 of 10

6 V5220 V5230 V5240 V5241 V5242 V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 Hearing aid, BICROS, behind the ear Hearing aid, BICROS, glasses Dispensing fee, BICROS Dispensing fee, monaural hearing aid, any type Hearing aid, analog, monaural, CIC Hearing aid, analog, monaural, ITC (in the canal) Hearing aid, digitally programmable analog, monaural, CIC Hearing aid, digitally programmable, analog, monaural, ITC Hearing aid, digitally programmable analog, monaural, ITE (in the ear) Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) Hearing aid, analog, binaural, CIC Hearing aid, analog, binaural, ITC Hearing aid, digitally programmable analog, binaural, CIC Hearing aid, digitally programmable analog, binaural, ITC Hearing aid, digitally programmable, binaural, ITE Hearing aid, digitally programmable, binaural, BTE Hearing aid, digital, monaural, CIC Hearing aid, digital, monaural, ITC Hearing aid, digital, monaural, ITE Hearing aid, digital, monaural, BTE Hearing aid, digital, binaural, CIC 6 of 10

7 V5259 V5260 V5261 V5264 V5265 V5266 Hearing aid, digital, binaural, ITC Hearing aid, digital, binaural, ITE Hearing aid, digital, binaural, BTE Ear mold/insert, not disposable, any type Ear mold/insert, disposable, any type Battery for use in hearing device MassHealth and Care Plus Only V5267 Hearing aid supplies/accessories Assistive listening device, not otherwise specified V5274 (Use this code only for pocket talkers or similar singleunit amplifiers.) V5275 Ear impression, each V5298 Hearing aid, not otherwise classified MassHealth Only V5299 Hearing service, miscellaneous Policy History Original Approval Original Effective Date Date Policy Owner Approved by 09/01/ /01/2006 Payment Policy Payment Policy Policy Revisions History Review Date Summary of Revisions 07/07/2007 Formatting review and changes to Responsibility and Accountability section. 06/05/2009 Removed maximum allowed markup for major repairs. Revision Effective Date Approved by 07/07/2007 Payment Policy 06/05/2009 Payment Policy 12/18/2009 Clarified reimbursement terms for acute outpatient hospital hearing aid dispensing. 12/18/2009 Payment Policy 04/28/2010 Updated definitions, minor repairs billing instructions, maximum 04/28/2010 Payment Policy 7 of 10

8 Policy Revisions History allowable units and nonreimbursable services; Updated coverage information: Effective July 1, 2010, the Plan will no longer cover hearing aids, hearing aid fittings/moldings, hearing aid batteries, or hearing aid repairs under the Commonwealth Care product; Inclusion of Mass Health Essential Product with non-coverage status. 09/20/2011 Deleted definitions, Invoice and Quotes reimbursement terms, and the Responsibility and Accountability table; Added Audiological Evaluation and Testing Services. 01/15/2013 Updated service limits on hearing aids for members 21 and younger to include $2000 for each hearing aid per 36 months; Updated coding; Added RT/LT modifiers for monaural hearing aids. 12/02/2013 Updated template and product applicability section for BMC HealthNet Plan Qualified Health Plans, including ConnectorCare; Added limitations and coding for ConnectorCare 09/20/2011 Payment Policy 01/15/2013 Payment Policy 12/02/2013 Payment Policy 04/15/2014 Annual review 04/15/2014 Payment Policy 12/17/2014 Clarified battery reimbursement eligibility 12/17/2014 Payment Policy 8 of 10

9 Policy Revisions History 05/28/2015 Annual Review, new template, removed Commonwealth Choice, Commonwealth Care, removed limitation on BTE hearing aid impressions 07/01/2015 Payment Policy Next Review Date 2016 Other Applicable Policies Reimbursement Policies General Billing and Coding Guidelines, 4.31 General Clinical Editing and Payment Accuracy Review Guidelines, Outpatient Hospital, 4.17 Physician and Non Physician Practitioner Services, Medical Policies Cochlear Implants, OCA Implantable Bone-Conduction (Bone-Anchored) Hearing Aids, OCA 3.30 References CMR Hearing Aid Dispensing Contract between The Office of Health and Human Services (EOHHS), and Boston Medical Center HealthNet Plan MassHealth The Commonwealth of Massachusetts General Laws, Part I, Title XXII, Chapter 175, Section 47X The Children s Hearing Aid Bill -Chapter 233 of the Acts of 2012 (HB 52) Disclaimer Information This Policy provides information about the Plan s reimbursement/claims adjudication processing guidelines. The use of this Policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan Provider agreement. Member cost-sharing (deductibles, coinsurance and copayments) may apply depending on the member s benefit plan. Unless otherwise specified in writing, reimbursement will be made at the lesser of billed charges or the contractual rate of payment. Plan policies may be amended from time to time, at Plan s discretion. Plan policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization guidelines (including NCQA). The Plan reserves the right to conduct Provider audits to ensure compliance with this Policy. If an audit determines that the Provider did not comply with this Policy, the Plan will expect the Provider to refund all payments related to non-compliance. For more information about the Plan s audit policies, refer to the Provider Manual. 9 of 10

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