Hearing Aid Dispensing and Repairs

Transcription

1 bmchp.org wellsense.org Reimbursement Policy Hearing Aid Dispensing and Repairs Policy Number: SCO Version Number: 1 Version Effective Date: 01/01/2016 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 Senior Care Options Note: Disclaimer and audit information is located at the end of this document. Policy Summary The Plan reimburses covered services based on the provider s contractual rates with the Plan and the terms of reimbursement identified within this policy. Prior-Authorization Please refer to the Plan s Prior Authorization Requirements Matrix at Definitions Hearing aid - a wearable aid or device designed for or offered for the purpose of aiding or compensating for hearing loss. 1 of 7

2 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 maintenance, minor repair, and servicing of the hearing aid that is furnished free of charge to non- Plan members The initial one-year manufacturer s warranty against loss or damage The loan of a hearing aid to the member, when necessary Major Repairs Payment for a major repair to a hearing aid made at a repair facility is limited to the following conditions: 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. 2 of 7

3 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, recasting) 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 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. 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 Ear Molds Ear molds are reported using HCPCS code V5264 or V5265. Reimbursement for ear molds includes: The ear impression The proper fitting of the earmold Any adjustments needed during the operational life of the earmold When an ear mold is included in the manufacturer s price of the hearing aid or the member already has an appropriate ear mold 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), in the canal (ITC) or behind-the-ear (BTE) hearing aid. Ear impressions are reported using HCPCS code V5275. Batteries Reimbursement for batteries includes new and unused batteries at the time of purchase. Batteries are reported using HCPCS code V5266. Accessories Payment for accessories and hearing-aid options includes proper fitting and adjustment of the accessory as needed. Accessories must be billed separately from the basic hearing-aid unit. Accessories 3 of 7

4 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 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. The Plan does not pay for any of the following services: o The rental of hearing aids o Personal FM systems, Bluetooth o Assistive technology devices provided under federal regulations 34 CFR o Hearing aids that are completely in the ear canal (CIC) 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. Split Claim Billing All related services must be reported on one claim. Subsequent related claims received after the initial claim will be denied. The initial claim must be resubmitted as a replacement claim. 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 4 of 7

5 V5010 V5011 V5014 V5030 V5040 V5050 V5060 V5070 V5080 V5090 V5100 V5110 V5130 V5140 V5150 V5160 V5170 V5180 V5190 V5200 V5210 V5220 V5230 V5240 V5241 V5243 V5245 V5246 V5247 V5249 V5251 V5252 V5253 V5255 V5256 V5257 Assessment for hearing aid Fitting/orientation/checking of hearing aid Repair/modification of a hearing aid 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 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 Hearing aid, BICROS, behind the ear Hearing aid, BICROS, glasses Dispensing fee, BICROS Dispensing fee, monaural hearing aid, any type Hearing aid, analog, monaural, ITC (in the canal) 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, ITC Hearing aid, digitally programmable analog, binaural, ITC Hearing aid, digitally programmable, binaural, ITE Hearing aid, digitally programmable, binaural, BTE Hearing aid, digital, monaural, ITC Hearing aid, digital, monaural, ITE Hearing aid, digital, monaural, BTE 5 of 7

6 V5259 V5260 V5261 V5264 V5265 V5266 V5267 V5274 V5275 V5298 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 Hearing aid supplies/accessories Assistive listening device, not otherwise specified (Use this code only for pocket talkers or similar single-unit amplifiers.) Ear impression, each Hearing aid, not otherwise classified Policy History Original Approval Original Effective Date Date Policy Owner Approved by 09/16/ /01/2016 Payment Policy SCO product subgroup Policy Revisions History Review Date Summary of Revisions Revision Effective Date Approved by Next Review Date 2017 Other Applicable Policies Reimbursement Policies General Billing and Coding Guidelines, SCO 4.31 General Clinical Editing and Payment Accuracy Review Guidelines, SCO Outpatient Hospital, SCO 4.17 Physician and Non Physician Practitioner Services, SCO References 101 CMR : HEARING AID DISPENSERS CMR Hearing Aid Dispensing MassHealth Hearing Instrument Specialist Manual 6 of 7

7 Medicare Benefit Policy Manual, Chapter 16 - General Exclusions from Coverage 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. 7 of 7