UNDER REVISION: REFER TO 7 AAC AAC 160 UNTIL REVISION IS COMPLETE

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1 Alaska Medical Assistance Program Hearing Services Provider Billing Manual AUGUST, 2006 Prepared By

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3 Dear Medical Assistance Provider: We are pleased to provide you with the enclosed provider billing manual to help you prepare your Medical Assistance claim forms. This billing manual has been prepared by First Health Services Corporation for the State of Alaska. First Health Services is the fiscal agent for the Alaska Department of Health and Social Services. The manual contains basic information on coverage and billing for medical services you provide to qualified recipients of our various medical assistance programs. It is designed to help you: 1) fill out health insurance claim forms for your eligible patients, 2) understand what medical services are reimbursable, and 3) understand the policies and procedures of these programs. As policies and procedures change, you will receive the updated information through bulletins and replacement pages to this manual. Your manual has been arranged in a loose-leaf format divided by sections and numbered so that replacement pages can be easily inserted. It is important to review and insert the updated information promptly to keep a current reference. Claim forms with outdated information may cause the automated payment system to reject the claim request. It is extremely important that you and your claims personnel follow the instructions described in the manual for your claims to be processed quickly and efficiently. It is our intention to make this manual useful to you, and we welcome any suggestions about the format that you believe would be helpful. Sincerely, Dwayne B. Peeples Director

4 Alaska Medical Assistance Program Provider Billing Manual How To Use This Manual Information about how to bill the Alaska Medical Assistance program for reimbursement of services rendered to medical assistance recipients is contained in this provider billing manual. Provider billing manuals are specific to type of service (for example, there are separate manuals for hospital, physician services, pharmacy, chiropractic, etc.). Manual pages are printed on three-hole paper and mailed to providers in a loose leaf format to make updating easy. The manuals are organized in three numbered sections to assist you in finding the information you need. Section I contains specific information about how to bill Medical Assistance for a particular type of service. Section II contains information about supplemental documents and instructions for payment reconciliation using the remittance advice (RA) statement. Section III contains general Medical Assistance program information. Appendices are included at the end of the manual for additional information. A Table of Contents is included at the beginning of each provider billing manual. Use the Table of Contents to help locate information in your manual. Updated 03/06 Current Procedural Terminology (CPT) Copyright Notice CPT codes, descriptions, and other data only are copyright 2005 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. Updated 01/06 Written Correspondence and Provider Training The provider billing manuals are meant to be used in conjunction with other provider communication, including Remittance Advice (RA) Messages, letters and other written correspondence, and information delivered at provider training seminars. An RA is issued weekly to providers with claims activity. The Message Page of the RA will contain important provider billing information (including new information, clarifications and reminders). Providers may be notified of changes in billing and reimbursement policy in weekly RA Messages. Revised manual pages are updated on the First Health Services Corporation Website and are periodically mailed to providers after the RA Messages are issued. Provider training topics, dates and locations are also announced in the RA Messages and on the First Health Services Corporation Website. For information, questions or suggestions about the provider billing manuals, other correspondence, or provider training, contact First Health Services Corporation or the Division of Health Care Services at the phone numbers or addresses listed on the Telephone Inquiries page. Updated 03/06 iv

5 First Health Services Corporation Telephone Inquiries Questions? Please call First Health Services Corporation at (907) or our in-state toll free number, (800) , about your participation in Alaska Medical Assistance. The First Health Services staff has been fully trained to answer most of your questions immediately. The following numbers can help you with other, more specific, questions: Billing Procedures (8:00 a.m. 5:00 p.m.) in-state toll free (800) (907) Claims & Eligibility Status (8:00 a.m. 5:00 p.m./claims) in-state toll free (800) (8:00 a.m. 5:00 p.m./eligibility) (907) Electronic Data Interchange (EDI) Electronic Commerce Customer Support (ECCS) Coordinator in-state toll free (800) (907) (907) Eligibility Verification System (EVS) (24-hour access) toll free (800) Enrollment (8:00 a.m. 5:00 p.m.) in-state toll free (800) (907) Fax for Provider Inquiry (PI) (907) or (907) for Prior Authorization (PA) (907) for EDI Attachments (907) or (907) for Resubmission Turnaround Documents (907) or (907) Prior Authorization (PA) (8:00 a.m. 5:00 p.m.) in-state toll free (800) (907) Provider Inquiry/Provider Services (8:00 a.m. 5:00 p.m.) in-state toll free (800) (907) Report Fraud, Waste, Abuse, or Misuse of the Medicaid Program by Providers or Recipients (24-hour access) toll free (800) Internet First Health Services Corporation Alaska Updated 04/04 v

6 Addresses Adjustment/Voids First Health Services Corporation P.O. Box Anchorage, AK Appeals: Claims: 1st Level 2nd Level Hospital, ESRD, and LTC (IHS) Indian Health Services Pharmacy All Others First Health Services Corporation Appeals P.O. Box Anchorage, AK Division of Health Care Services Claims Appeal Section 4501 Business Park Boulevard, Suite 24 Anchorage, AK First Health Services Corporation P.O. Box Anchorage, AK P.O. Box Anchorage, AK P.O. Box Anchorage, AK P.O. Box Anchorage, AK Electronic Media Claims (EMC)/Electronic Commerce Customer Support (ECCS) Enrollment Inquiries and Correspondence Prior Authorization SURS (Surveillance and Utilization Review Subsystem) First Health Services Corporation EMC Department/ECCS Department P.O. Box Anchorage, AK First Health Services Corporation Provider Enrollment P.O. Box Anchorage, AK First Health Services Corporation Provider Services Unit P.O. Box Anchorage, AK First Health Services Corporation Prior Authorization Unit P.O. Box Anchorage, AK First Health Services Corporation Surveillance and Utilization Review P.O. Box Anchorage, AK Updated 04/04 vi

7 State of Alaska Alaska Department of Health and Social Services * Internet Web Site: UNDER REVISION: REFER TO 7 AAC Call: (907) Alaska Medical Assistance/Division of Health Care Services Internet Web Site: Call: (907) Medicaid Provider Fraud Control Unit, Department of Law To report fraud of the Medicaid program by providers Call: (907) Write: Medicaid Provider Fraud Control Unit State of Alaska, Department of Law Criminal Division 310 K Street, Suite 300 Anchorage, AK Fraud Control Unit, Division of Public Assistance, Department of Health and Social Services To report recipient Fraud and Abuse of Medicaid and other public assistance programs Call: Write: Toll free: (800) In Anchorage (907) In Wasilla (907) In Kenai (907) In Fairbanks (907) Fraud Control Unit State of Alaska, DHSS Division of Public Assistance 3601 C Street, Suite 200 Anchorage, AK Updated 08/04 * For more contact information, see Appendix A. vii

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9 Table of Contents Hearing Services Introductory Letter... iii How To Use This Manual... iv Telephone Inquiries... v Addresses... vi Section I Hearing Services Policies and Claims Billing Procedures I-1 Provider Participating Requirements, Services and Items...I-1 Out-of-state Providers...I-1 Service Limitations...I-1 Services of an Audiologist...I-1 Physician Collaborators...I-2 Services of a Hearing Aid Dealer...I-2 Treatment Plan...I-3 Recipient s Right to Choose...I-3 Hearing Items...I-3 Personal FM Systems...I-4 Assistive Listening Devices...I-5 Rental of a Hearing Aid...I-5 Cochlear Implant Services...I-6 Cochlear Implant Batteries and Accessories...I-7 Prior Authorizations for Hearing Services...I-8 Prior Authorization Requests and Documents...I-10 Procedure Codes...I-11 Table I-2(a) CPT Fee Schedule for Audiology Services...I-12 Table I-2(b) HCPC Fee Schedule for Audiology Services...I-15 Table I HCPC Fee Schedule For Hearing Aid Dealer Services...I-17 Delivery Expenses...I-19 Labor and Repair of Hearing Items...I-19 Recipient Eligibility...I-20 Verification...I-20 Eligibility Codes...I-21 Table I-4. Hearing Services Eligibility Codes...I-21 Reimbursement...I-22 General...I-22 Pricing Methodology...I-22 Rental of Hearing Equipment and Accessories...I-23 TPL (Third Party Liability)...I-23 Federal TPL Waiver...I-24 Recipients with VA, Medicare, and Medicaid...I-24 Obtaining a VA Medicaid Denial Letter...I-25 Providers Can Attach Other Insurance Benefit Booklet Pages...I-26 Hearing Services ix

10 Third Party Liability (TPL) Avoidance...I-26 Claims Billing Procedures...I-29 Claims: General Instructions...I-29 Claims: Specific Instructions...I-29 Payerpath...I-29 X12N 837 Version I-29 Health Insurance Claim Form (CMS-1500) Instructions...I-29 Medicare/Medical Assistance Crossover Billing...I-34 Completing the Medicare/Medical Assistance Crossover Billing...I-34 Section II Supplemental Documents and Instructions Attachments to the Claim Form... II-1 Unlisted Procedure Code Explanation... II-1 Proof of Timely Filing Documentation... II-1 Electronic Claims Attachment Transmittal... II-1 Insurance Explanation of Benefits (EOB)... II-3 Explanation of Medicare Benefits/Medicare Remittance Notice (EOMB/MRN) or Medicare Payment Report... II-3 Prior Authorization Request (AK-PA)... II-4 Requesting Authorization... II-4 Requesting Retroactive Authorization... II-4 Completing the Prior Authorization Request (AK-PA): By Provider... II-5 Reviewing the Prior Authorization Request (AK-PA)... II-6 Completing the Prior Authorization Request (AK-PA): By FHSC... II-7 Correcting Errors on the Prior Authorization Request (AK-PA)... II-7 Submitting the Claim... II-7 Requesting Unlisted Code Review... II-7 Transportation Authorization and Invoice (AK-04)... II-9 Requesting Transportation/Accommodation Services... II-9 Step By Step... II-9 Remittance Advice... II-13 Cover Page... II-13 Message Page... II-14 Adjudicated Claims (Paid and Denied Claims)... II-15 Adjustment Claims... II-17 Voided Claims... II-19 In-Process Claims... II-19 Financial Transactions... II-21 EOB Description Page... II-22 Remittance Summary... II-24 Resubmission Turnaround Document (RTD)... II-27 Adjustment/Void Request Form (AK-05)... II-30 General Guidelines... II-30 Adjustment... II-30 Void... II-31 Overpayment/Refund... II-31 Completing the Adjustment/Void Request Form (AK-05)... II-32 Claim Inquiry Form (AK-11)... II-35 General Guidelines... II-35 Completing the Claim Inquiry Form (AK-11)... II-35 Forms Order Request... II-37 II-1 x Hearing Services

11 Section III Alaska Medical Assistance Program General Program Information UNDER REVISION: REFER TO 7 AAC Program Introduction...III-1 Program Background...III-1 Program Objectives...III-1 Program Fiscal Agent...III-1 Table III-1. Guidelines to Efficient Telephone Inquiries...III-2 Provider Billing Information...III-2 Claims Processing Overview...III-2 HCPCS Coding...III-3 Unlisted Codes...III-3 Diagnosis Codes...III-3 Coding Updates...III-4 Claims Submission...III-4 Table III-2. Advantages of EDI Transactions...III-4 Computer Operations...III-4 Adjudication...III-4 Payment...III-5 Services...III-5 Medical Assistance Covered Services...III-5 Chronic and Acute Medical Assistance (CAMA) Covered Services...III-6 Denali KidCare...III-7 SeniorCare Rx Program...III-8 Out-of-State Services...III-8 Medically Necessary Services...III-9 Medical Assistance Providers...III-9 Eligible Providers...III-9 Non-Eligible Providers...III-11 Provider Enrollment Requirements...III-11 Eligible Recipients...III-13 Recipient Residency Requirements...III-13 One-Day/One-Month Eligibility...III-14 Eligibility Verification System (EVS)...III-14 Table III-3. Advantages of EVS...III-14 Medical Authorization: ID Cards and Coupons...III-14 Table III-4. Codes on Recipient s Card or Coupon...III-15 Medical Assistance Eligibility Codes...III-18 Table III-5. Medical Assistance Eligibility Codes...III-18 Chronic and Acute Medical Assistance (CAMA) Subtype...III-19 Table III-6. CAMA Eligibility Subtype...III-19 Resource Codes...III-19 Retroactive Eligibility for Eligible Medical Assistance Recipients...III-21 Eligible Chronic and Acute Medical Assistance (CAMA) Recipients...III-21 Regulations and Restrictions...III-21 Discriminatory Practices...III-21 Surveillance and Utilization Review for Fraud, Waste, Abuse, or Misuse...III-22 Medicaid Provider Fraud Control Unit...III-22 Timely Filing of Claims...III-22 Eligible Medical Assistance Recipients...III-23 Conditions for Payment...III-24 Recovery or Recoupment of an Overpayment...III-25 Appeals Process...III-26 III-1 Hearing Services xi

12 Glossary... Glossary-1 UNDER REVISION: REFER TO 7 AAC Appendix A Directory Assistance... A-1 Appendix B Julian Date Calendar... B-1 Appendix C Surveillance and Utilization Review... C-1 Appendix D Forms... D-1 Appendix E CPT-4 Claim Coding Guidelines... E-1 Appendix F Transportation and Accommodation Resource Materials...F-1 Appendix G Telemedicine... G-1 Table of Contents Updated 08/06 xii Hearing Services

13 Section I Hearing Services Policies and Claims Billing Procedures UNDER REVISION: REFER TO 7 AAC Provider Participating Requirements, Services and Items Audiology hearing services include audiometric evaluation, diagnostic testing, audiometric screening, rehabilitative therapy, preventive, corrective, hearing items, and hearing item repairs furnished to eligible recipients of all ages. The need must be medically necessary, and prescribed to alleviate disability caused by the loss or impairment of hearing. Alaska Medical Assistance covered audiology services, hearing items/repairs, related accessories, and supplies billing codes are listed in Table I-2(a)(b) for Audiology Services and in Table I-3 for Hearing Aid Dealer Services. The department may enroll an audiologist licensed under AS who is practicing individually or in a group, or a hearing aid dealer licensed under AS 08.55, as providers of hearing services and items. The department will pay an enrolled audiologist for services such as diagnostic, evaluation, preventative, screening, rehabilitative, corrective, hearing items, and hearing item repairs for an eligible recipient. Out-of-state Providers Updated 08/06 To be paid by the department, an out-of-state audiologist and hearing aid dealer must be licensed and enrolled in the Medicaid program in the state where the services are provided and enrolled as a Medical Assistance provider in Alaska. Refer to Section III for detailed information regarding general enrollment requirements. Service Limitations Updated 08/06 Reimbursement to and interaction with providers are governed by Alaska Medical Assistance provider manuals, fee schedules, and other materials that are written in accordance with the Alaska Administrative Code (AAC). Hearing service providers are responsible for reading and understanding 7 AAC , Hearing Services. Services of an Audiologist Updated 08/06 The department will pay an enrolled provider for services rendered within the scope of the practitioner s license. An audiologist is allowed to diagnose hearing loss as long as the diagnosis is limited to information from audiologic testing and relates to hearing loss. The plan of care and audiologic test results must be kept on file at the business location. Prior authorization requests and/or claims must include the: diagnosis code/description, audiometric examination results indicating special needs, special circumstances, patient history and lifestyle, prior authorization number when assigned, warranty length of coverage, Hearing Services I-1

14 purchase date of previous used hearing devices, a copy of the hearing item original Manufacturer s Suggested Retail Price (MSRP) information invoice that indicates: o o o the brand name, model number, and serial number. The claim must indicate if the hearing item or service is for the left, right or both ears. When billing for a dispensing fee, the provider is to submit the services included for the fee with the claim. Covered services are identified in Table I-2(a)(b). Updated 08/06 UNDER REVISION: REFER TO 7 AAC Physician Collaborators Audiologists may provide services as a physician collaborator. A physician collaborator does not need to enroll separately in Alaska Medical Assistance, but must be employed by, in a contractual relationship with, or supervised by a physician enrolled in Alaska Medical Assistance. The physician assumes professional responsibility for the services, assures that the services are medically appropriate, bills and is reimbursed for the physician collaborator services. All services rendered by the physician collaborator must be billed with modifier SA. Services of a Hearing Aid Dealer Updated 08/06 The department will pay an enrolled provider for hearing devices, accessories, supplies, repairs, and covered services for an eligible recipient when ordered, if applicable, by a physician, audiologist, otologist, otolaryngologist, or other licensed health care practitioner who has received training to administer hearing assessments and may prescribe the hearing item or service within the scope of their license. Submitted claims and/or prior authorization requests require: a copy of the prescription, the prescriber s medical necessity notes, the audiometric examination results including o special needs, o special circumstances, o patient history and lifestyle, prior authorization number when applicable, warranty length of coverage, a copy of the hearing item original Manufacturer s Suggested Retail Price (MSRP) information invoice that indicates the o brand name, o model number, and o serial number. All supporting documents must be kept on file at the business location. When a specific device is prescribed, the hearing aid dealer must dispense as written indicating left, right or both ears on the claim. The provider must itemize any services that are part of the billed dispensing fee, and submit it with the claim. I-2 Hearing Services

15 The physician-signed prescription is required, at a minimum, to state: (1) the recipient s diagnosis code/description, (2) the least costly hearing device that meets the recipient s medical need, and (3) that the recipient is a hearing aid candidate for left, right or both ears. Covered services are identified in Table I-3. The department will pay for a hearing aid if: (1) the hearing aid is prescribed by a physician, when required; and (2) the requirements of AS (a) and (b) are met. The department will not pay an enrolled hearing aid dealer: if the recipient has waived the hearing evaluation under AS (c), or for a hearing test or for diagnostic procedures designed to determine the cause of a hearing impairment. Updated 08/06 UNDER REVISION: REFER TO 7 AAC Treatment Plan Hearing therapy services require a treatment plan that includes a copy of the prescription requesting the services, signed by a licensed physician. The audiologist must keep the treatment plan on file. A treatment plan includes any or all of the following: Lip reading Auditory training Hearing device use Cochlear Implant progress Recipient s Right to Choose Updated 08/06 Unless a recipient is restricted to a particular hearing service provider in accordance with the Alaska Administrative Code, he or she has the right to use hearing services through the provider of choice. Those who seek services on behalf of a recipient should ask the recipient if he or she has a preference of providers. First Health Services can provide a list of currently enrolled hearing service providers. If a recipient has an established PA with a specific provider and wants to change to a different provider, he or she may do so by contacting a new hearing service provider and asking to begin the Transfer PA Process. Hearing Items Updated 08/06 All hearing items such as hearing devices/hardware, accessories, and supplies must include direct auditory input capabilities. Services for hearing items must be submitted separately using the identifying CPT and HCPCS codes listed in Table I-2(a)(b) and Table I-3. The provider must bill the date the recipient receives the hearing item as the date of service. Misuse or abuse of a hearing item by the recipient does not warrant replacement charges. All hearing items and repair of hearing items must be warranteed for one (1) year or longer from the date received by the recipient. Specific items identified in Table I-2(a)(b) and Table I-3 require prior authorization or medical justification. For details, see Prior Authorizations for Hearing Services and Prior Authorization Requests and Documents, later in Section I. All prior authorization requests for hearing items and services may be Hearing Services I-3

16 requested electronically or submitted in writing using the Certificate of Medical Necessity (CMN) twopage form, located in Appendix D of the manual. The provider must attach a copy of the original Manufacturer s Suggested Retail Price (MSRP) information invoice and supporting documents with the claim as indicated for CPT and HCPCS codes listed in Table I-2(a)(b) and Table I-3. The department will only pay for UNDER REVISION: REFER TO 7 AAC (1) one hearing aid per ear, per recipient, per five calendar years, including the ear mold impressions and hearing instrument accessories; hearing instrument accessories includes the: single cord, Y-cord, harness, new receiver, and bone-conduction receiver with headband; (2) one dispensing fee per hearing aid (itemize services included); and (3) 20 hearing aid batteries per month up to 100 per year for an eligible recipient for whom the department has paid for the rental or purchase of a hearing aid. Personal FM Systems Updated 08/06 Alaska Medical Assistance will cover personal FM systems. Prior authorization is required. The prior authorization request must include the following: Manufacturer s Suggested Retail Price (MSRP) Warranty information Medical justification Personal FM systems are covered if the following criteria are met: Unilateral or bilateral hearing loss as diagnosed by an audiologist licensed in Alaska Statement of audiological status and necessity for the system by a licensed audiologist Restricted to recipients under 21 years of age Approved authorization Updated 08/06 I-4 Hearing Services

17 Assistive Listening Devices The department will not pay for the following devices identified as an assistive listening device in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS) 2006, as amended from time to time and adopted by reference: telephone amplifiers; alerters; television amplifiers; television caption decoders; telecommunication devices for the deaf (TDD); devices for use with cochlear implants. Updated 08/06 Rental of a Hearing Aid The department will not authorize the rental of a hearing aid if the rental price would be more expensive than the purchase price. The department will pay an enrolled provider for the rental or rental-to-purchase of a hearing aid as follows: for a rental period that is 30 days or longer, the department will pay a monthly rental fee that is equal to 10 percent of the allowed purchase price; for a rental period that is less than 30 days, the department will pay an amount equal to the monthly rental fee divided by the number of days in the month, times the number of days in the rental period; the department will not pay a rental fee for a rental period that exceeds 12 months of continuous use; if the length of need is more than 12 months of continuous use, the prescriber must administer another hearing assessment and request prior authorization for purchase of a new hearing aid; the department will pay the difference between the allowed purchase price and the total monthly rental fees already paid by the department if the provider (a) transfers ownership of the hearing aid, including any warranty, to the recipient for whom it was rented; and (b) replaces the rented hearing aid with a new hearing aid if the rented hearing aid was previously used by anyone other than the recipient before it was rented to the recipient; before the total rental fee payments equal the allowed purchase price, the department will not separately pay the cost of repairs and maintenance; repairs and maintenance must be included in the rental fee and must be documented in the rental agreement; when total rental payments reach the allowed purchase price of a new hearing aid, the department will pay the cost of repair and maintenance after 60 days or when the warranty expires, whichever is later. The department will not pay a hearing aid dealer for a hearing test or diagnostic procedure designed to determine the cause of a hearing impairment. Hearing Services I-5

18 The department will not pay separately for administrative expenses. The following costs are considered administrative expenses and are included in the payment for the equipment: telephone responses to questions; mileage; travel expenses; travel time; equipment set up; installation; delivery and dispensing charges from the manufacturer to the supplier to maintain inventory; orientation and training regarding the proper use of equipment. Updated 08/06 Cochlear Implant Services Alaska Medical Assistance covers cochlear implants when approval has been granted through prior authorization. The plan of care must be submitted when requesting prior authorization for cochlear implant service and kept on file at the provider s business location. The implantation process consists of several stages. Each stage has separate reimbursement criteria. Individuals progress through the stages on a case-by-case basis. The department will pay an enrolled audiologist separately for services related to cochlear implantation, including: a preliminary assessment; programming of the cochlear device; adjustments; education; auditory rehabilitation; and treatment sessions. The department will pay for an auditory rehabilitation evaluation session following a cochlear implantation on a one-session-per-month basis; and only if rendered by (a) the audiologist, otologist, otolaryngologist, or physician who performed the cochlear implant procedure; or (b) an enrolled health care practitioner practicing within the practitioner s license if referred by a practitioner in (a) of this paragraph who is unavailable to render the rehabilitation evaluation sessions at that time outlined in the recipient s plan of care. Cochlear implantation may require travel to another state (see Appendix F for general information about travel reimbursement). Travel schedules for such services require prior authorization and are approved to meet the individual recipient s medical needs. Services that qualify for travel may include: I-6 Hearing Services

19 Preliminary assessment by the surgeon who will perform the implant. An Alaska audiologist, otologist or otolaryngologist can refer the recipient to the surgeon. Travel for this purpose is typically approved for one outpatient visit (1 business day of travel). Surgery to implant the cochlear device. Travel for this purpose is typically approved for 4 business days, which accommodate pre-operative, surgical, and post-operative time frames. Programming of the cochlear device. Travel for this purpose is typically approved for 5 business days, which is intended to encompass the time frame necessary for 3 to 4 visits to the surgeon for adjustments as well as education for the recipient and his or her guardian. This stage often occurs 3 to 4 weeks after the implantation, when the recipient returns to the surgeon to have the device activated. Adjustments and education. Travel for this purpose is typically approved for 2 consecutive business days per month for 3 months following activation of the cochlear device. This is intended to accommodate a minimum of two educational sessions per trip. Further adjustments and education. Travel for this purpose is typically approved for one trip every 3 months for three intervals, followed by one trip every 6 months for four intervals, and then by one trip per year, or as medically indicated for emergencies or infection. Travel authorizations for cochlear implants are not approved if authorization for the cochlear surgery does not correlate with the policy requirements of Alaska Medical Assistance and its fiscal agent, First Health Services. Travel for the preliminary assessment, however, need not comply with this guideline. Alaska Medical Assistance will authorize one adult to travel with a minor recipient. Updated 08/06 Cochlear Implant Batteries and Accessories The department will only pay for: 21 cochlear implant alkaline batteries per month; and 45 cochlear implant zinc air batteries per month. The department will not separately pay a provider for the initial external parts of a cochlear implant. The initial external parts consist of the: microphone; speech processor; and transmitter. Updated 08/06 Hearing Services I-7

20 Prior Authorizations for Hearing Services Prior authorization is required from the department before payment will be made for the purchase of semi-implantable, middle-ear hearing prostheses; the following items and services identified as miscellaneous in Healthcare Common Procedure Coding System (HCPCS) 2006, as amended from time to time and adopted by reference in this section: (a) personal FM systems, for a recipients under 21 years of age with hearing losses diagnosed by an audiologist licensed under AS 08.11; (b) assistive listening devices; (c) hearing aids; (d) hearing aid batteries; (e) hearing aid accessories; (f) hearing aid supplies; (g) hearing services; replacement cochlear implant parts or rechargeable lithium ion batteries; the rental of hearing aids; hearing aids, accessories, batteries, or supplies that exceed limits set by the department; the department will not give prior authorization for more than two ear molds per ear per year; payment requests that exceed the maximum allowable payment for an item; customized hearing aids; services or accessories related to cochlear implants; auditory rehabilitation evaluation sessions, in excess of more than one per month; or digitally programmable hearing aids or digital hearing aid. A request for prior authorization for a hearing item/device or service not mentioned below may be submitted electronically or in writing on a Certificate of Medical Necessity two-page form, provided by the department, and located in Appendix D of the manual. The request must include: documentation of medical necessity by a licensed health care practitioner trained to administer hearing assessments and evaluations and practicing within the scope of the practitioner s license; a prescription signed by a physician if the request is from a hearing aid dealer indicating the recipient s diagnosis code/description, least costly hearing device that meets the recipient s medical need, if device is for the left, right or both ears and that the recipient is a candidate for a hearing aid; audiometric examination results including special needs, special circumstances, patient history and lifestyle; warranty length of coverage; a copy of the hearing item original Manufacturer s Suggested Retail Price (MSRP) information invoice that indicates the brand name, model number, and serial number, if available; I-8 Hearing Services

21 information pertaining to previous used hearing devices including purchase date; manufacturer information; the item description or number; the Global Trade Item Number (GTIN), if available; the suggested price; and the serial number, if available. A request for prior authorization for a cochlear implant must include: UNDER REVISION: REFER TO 7 AAC (1) results from a comprehensive audiological test and assessment administered by an audiologist, otologist, otolaryngologist, physician, advanced nurse practitioner, or licensed health care practitioner trained to administer hearing assessments and practicing within the scope of the practitioner s license; the results must show: (a) a diagnosis of bilateral moderate to profound sensorineural hearing impairment with limited benefit from a hearing aid; (b) inconsistent audiometric findings, if any; (c) cognitive ability to use auditory clues; (d) a willingness by the recipient, or recipient s guardian if the recipient is a minor, to undergo an extended program of rehabilitation; (e) no known middle-ear infection or lesions in the auditory nerve and acoustic area of the central nervous system; (f) an accessible cochlear lumen that is structurally suited to implantation; and (g) no contraindications to surgery; (2) X-rays and MRI reports; and (3) results of a physical examination administered by a physician and completed within 12 weeks preceding the date of the prior authorization request. A request for prior authorization for an auditory rehabilitation evaluation session must include: (1) a documented treatment plan of care that is (a) outlined in no less than six-month increments not to exceed 12 months; and (b) signed by the audiologist, otologist, otolaryngologist, or physician who performed the cochlear implant surgery; (2) the billing codes from the American Medical Association s Current Procedural Terminology (CPT) 2006, as amended from time to time and adopted by reference; and (3) the charge amount indicated by each billing code for the requested sessions. A request for prior authorization for a payment request that exceeds the maximum allowable payment for an item must include a written statement of medical necessity that the recipient s condition requires the more costly item. Hearing Services I-9

22 A request for prior authorization for a replacement hearing aid or hearing aid accessory must show that the item is necessary to replace an item that is under repair; is necessary to replace an item that has been in continuous use by the recipient for the item s reasonable useful lifetime; or is not covered by a manufacturer s warranty and is determined to be damaged as the result of a manufacturing defect. The department will give prior authorization if the request complies with the criteria in this section; the department has determined that the item is lost or irreparably damaged; a less expensive alternative item is not available, if the (a) request exceeds the maximum allowable payment for the item; or (b) item is identified only as miscellaneous in Healthcare Common Procedure Coding System (HCPCS) 2006, as amended from time to time and adopted by reference; and payment is appropriate under this section. Updated 08/06 UNDER REVISION: REFER TO 7 AAC Prior Authorization Requests and Documents Hearing devices/hardware, replacements, supplies, and accessories may require prior authorization, as indicated in Table I-2 (a)(b) and Table I-3. For items that require prior authorization, the provider is responsible for preparing the prior authorization request and forwarding it to the PA unit at First Health Services for processing. Refer to Section II of this manual for the procedure to request prior authorization. The prior authorization request may be submitted electronically or in writing on the two-page Certificate of Medical Necessity form, provided by the department and located in Appendix D of the manual. All prior authorization requests for hearing items and services from enrolled Alaska Medical Assistance providers must be accompanied by a signed physician prescription when required, prescriber s medical necessity notes and MSRP. Supporting documents and test results must include the diagnosis code, diagnosis description, and specify if the item or service is for the left ear, right ear or both ears. The Alaska Administrative Code mandates that prior authorizations are issued prospectively. First Health will enter the primary diagnosis code for the requested item or service into the prior authorization record in the Medicaid Management Information System (MMIS). Any corresponding claims must include the same primary diagnosis for the service or item. All requests must include the enrolled ordering provider s Alaska Medical Assistance assigned identification number. Unlisted codes may be used in the following circumstances: There is no other valid code to describe the product or service. The product or service in Table I-2(a)(b) or Table I-3 is insufficient to meet the recipient s specific medical need. All prior authorization requests for hearing devices/hardware must include a published retail price sheet from the manufacturer or distributor of the product. If a published retail price sheet is not available, the provider must state that this is the case in the submitted documentation. Instead, a price quote, invoice, or other proof of cost to the provider must be submitted. I-10 Hearing Services

23 If authorization is requested for a product or service with a valid code but which exceeds the lowest quoted price, the provider must attach an assessment explaining why the less expensive item will not meet the recipient s needs. Updated 08/06 UNDER REVISION: REFER TO 7 AAC Procedure Codes Specific procedure codes must be used to complete the claim form. Codes for covered audiology services are listed in Table I-2(a)(b) and codes for covered hearing aid dealer services are listed in Table I-3. Note: Procedure code V5011, Fitting/Orientation/Checking of Hearing Aid, can be provided by hearing aid suppliers as well as audiologists. Unlisted services that cannot be billed under an identified procedure code are billed under Procedure Code ( Unlisted Otorhinolaryngological Service or Procedure ). A written explanation must be attached behind your claim when using and other procedures that require written justification (such as procedure codes V5298 and V5014, requiring an invoice of charges with the claim). See Section II of this manual for further discussion. Pricing for unlisted codes and unpriced items (those that state By Report as the maximum allowable amount in Table I-2 (a)(b) and Table I-3) requires prior authorization. The provider is responsible for preparing the prior authorization request and forwarding it to the Prior Authorization (PA) unit at First Health Services Corporation for processing. Updated 08/06 Hearing Services I-11

24 Table I-2(a) CPT 1 Fee Schedule for Audiology Services Code Description Maximum Allowable Removal foreign body from ex $ Removal impacted cerumen (se $ Evaluation of speech, langua $ Treatment of speech, languag $ Treatment of speech, languag $ Facial nerve function studie $ Positional nystagmus test $ Spontaneous nystagmus test, $ Positional nystagmus test, m $ Caloric vestibular test, eac $ Optokinetic nystagmus test, $ Oscillating tracking test, w $ Sinusoidal vertical axis rot $ Use of vertical electrodes ( $ Computerized dynamic posturo $ Screening test, pure tone, a $ Pure tone audiometry (thresh $ Pure tone audiometry (thresh $ Speech audiometry threshold $ Speech audiometry threshold; $ Comprehensive audiometry thr $ Bekesy audiometry; screening $ Bekesy audiometry; diagnosti $ Loudness balance test, alter $ Tone decay test $ Short increment sensitivity $ Stenger test, pure tone $ Tympanometry (impedance test $ Acoustic reflex testing; thr $ Acoustic reflex testing; dec $ Filtered speech test $ Staggered spondaic word test $ Lombard test $ CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Audiology Services Applicable FARS/DFARS apply. Coverage and rates are subject to change Effective 1/11/2006 Dates of Service * = PA Required # = Medical Justification or Written Report Required 7/31/2006 I-12 CPT code descriptions are shortened to 28 characters or less to comply with copyright restrictions. For full descriptions, please refer to your 2006 CPT book.

25 Table I-2(a) CPT 1 Fee Schedule for Audiology Services Code Description Maximum Allowable Sensorineural acuity level t $ Synthetic sentence identific $ Stenger test, speech $ Visual reinforcement audiome $ Conditioning play audiometry $ Select picture audiometry $ Electrocochleography $ Auditory evoked potentials f $ Auditory evoked potentials f $ Evoked otoacoustic emissions $ Evoked otoacoustic emissions $ Hearing aid examination and $ Hearing aid examination and $ Hearing aid check; monaural $ Hearing aid check; binaural $ Electroacoustic evaluation f $ Electroacoustic evaluation f $ Ear protector attenuation me $ Evaluation for use and/or fi $ Diagnostic analysis of cochl $ Diagnostic analysis of cochl $ Diagnostic analysis of cochl $ Diagnostic analysis of cochl $ Evaluation for prescription $ Therapeutic service(s) for t $ Evaluation for prescription $ Evaluation for prescription $ Therapeutic services for the $ Evaluation of oral and phary $ Evaluation of central audito $ Evaluation of central audito $ Assessment of tinnitus (incl $ # Evaluation of auditory rehab $ CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Audiology Services Applicable FARS/DFARS apply. Coverage and rates are subject to change Effective 1/11/2006 Dates of Service * = PA Required # = Medical Justification or Written Report Required 7/31/2006 I-13 CPT code descriptions are shortened to 28 characters or less to comply with copyright restrictions. For full descriptions, please refer to your 2006 CPT book.

26 Table I-2(a) CPT 1 Fee Schedule for Audiology Services Code Description Maximum Allowable Evaluation of auditory rehab $ Auditory rehabilitation; pre $ Auditory rehabilitation; pos By Report * Unlisted otorhinolaryngologi 50% of Billed Charges Development of cognitive ski $ Sensory integrative techniqu $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ Office or other outpatient v $ CPT codes and descriptions only are copyright 2005 American Medical Association. All Rights Reserved. Audiology Services Applicable FARS/DFARS apply. Coverage and rates are subject to change Effective 1/11/2006 Dates of Service * = PA Required # = Medical Justification or Written Report Required 7/31/2006 I-14 CPT code descriptions are shortened to 28 characters or less to comply with copyright restrictions. For full descriptions, please refer to your 2006 CPT book.

27 Table I-2(b) HCPC Fee Schedule for Audiology Services Code Description Maximum Allowable L7510 # Repair of prosthetic device, repair or replace minor parts By Report L7520 Repair prosthetic device, labor component, per 15 minutes $20.00 L8615 * Headset/headpiece for use with cochlear implant device, replacement By Report L8616 * Microphone for use with cochlear implant device, replacement By Report L8617 * Transmitting coil for use with cochlear implant device, replacement By Report L8618 * Transmitter cable for use with cochlear implant device, replacement By Report L8619 * Cochlear implant external speech processor, replacement By Report L8621 Zinc air battery for use with cochlear implant device, replacement, each $1.00 L8622 Alkaline battery for use with cochlear implant device, any size, replacement, each By Report L8623 * Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each L8624 * Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each By Report By Report V5008 Hearing screening $20.00 V5010 Assessment for hearing aid By Report V5011 Fitting/orientation/checking of hearing aid $ V5014 # Repair/modification of a hearing aid $ V5020 Conformity evaluation By Report V5030 Hearing aid, monaural, body worn, air conduction By Report V5040 Hearing aid, monaural, body worn, bone conduction By Report V5050 Hearing aid, monaural, in the ear By Report V5060 Hearing aid, monaural, behind the ear By Report V5090 # Dispensing fee, unspecified hearing aid By Report V5130 Binaural, in the ear By Report V5140 Binaural, behind the ear By Report V5180 Hearing aid, cros, behind the ear By Report V5220 Hearing aid, bicros, behind the ear By Report V5242 Hearing aid, analog, monaural, cic (completely in the ear canal) By Report V5243 Hearing aid, analog, monaural, itc (in the canal) By Report V5244 * Hearing aid, digitally programmable analog, monaural, cic By Report * # = PA Required = Medical Justification or Written Report Required I-15 Audiology Services Coverage and rates are subject to change Effective 1/11/2006 Dates of Service 7/31/2006

28 Table I-2(b) HCPC Fee Schedule for Audiology Services Code Description Maximum Allowable V5245 * Hearing aid, digitally programmable, analog, monaural, itc By Report V5246 * Hearing aid, digitally programmable analog, monaural, ite (in the ear) By Report V5247 * Hearing aid, digitally programmable analog, monaural, bte (behind the ear) By Report V5248 Hearing aid, analog, binaural, cic By Report V5249 Hearing aid, analog, binaural, itc By Report V5250 * Hearing aid, digitally programmable analog, binaural, cic By Report V5251 * Hearing aid, digitally programmable analog, binaural, itc By Report V5252 * Hearing aid, digitally programmable, binaural, ite By Report V5253 * Hearing aid, digitally programmable, binaural, bte $1, V5254 * Hearing aid, digital, monaural, cic By Report V5255 * Hearing aid, digital, monaural, itc By Report V5256 * Hearing aid, digital, monaural, ite By Report V5257 * Hearing aid, digital, monaural, bte By Report V5258 * Hearing aid, digital, binaural, cic By Report V5259 * Hearing aid, digital, binaural, itc By Report V5260 * Hearing aid, digital, binaural, ite $2, V5261 * Hearing aid, digital, binaural, bte By Report V5264 Ear mold/insert, not disposable, any type $50.00 V5265 Ear mold/insert, disposable, any type $50.00 V5266 Battery for use in hearing device $0.90 V5267 # Hearing aid supplies / accessories By Report V5274 * Assistive listening device, not otherwise specified By Report V5275 Ear impression, each $70.00 V5298 * Hearing aid, not otherwise classified By Report V5299 * Hearing service, miscellaneous By Report * # = PA Required = Medical Justification or Written Report Required I-16 Audiology Services Coverage and rates are subject to change Effective 1/11/2006 Dates of Service 7/31/2006

29 Table I HCPC Fee Schedule For Hearing Aid Dealer Services Code Description Maximum Allowable L7510 # Repair of prosthetic device, repair or replace minor parts L7520 Repair prosthetic device, labor component, per 15 minutes L8615 * Headset/headpiece for use with cochlear implant device, replacement L8616 * Microphone for use with cochlear implant device, replacement L8617 * Transmitting coil for use with cochlear implant device, replacement L8618 * Transmitter cable for use with cochlear implant device, replacement L8619 * Cochlear implant external speech processor, replacement L8621 L8622 Zinc air battery for use with cochlear implant device, replacement, each Alkaline battery for use with cochlear implant device, any size, replacement, each L8623 * Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each L8624 * Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each V5011 Fitting/orientation/checking of hearing aid V5014 # Repair/modification of a hearing aid V5030 V5040 V5050 V5060 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 V5090 # Dispensing fee, unspecified hearing aid V5130 V5140 V5180 V5220 V5242 V5243 Binaural, in the ear Binaural, behind the ear Hearing aid, cros, behind the ear Hearing aid, bicros, behind the ear Hearing aid, analog, monaural, cic (completely in the ear canal) Hearing aid, analog, monaural, itc (in the canal) V5244 * Hearing aid, digitally programmable analog, monaural, cic V5245 * Hearing aid, digitally programmable, analog, monaural, itc V5246 * Hearing aid, digitally programmable analog, monaural, ite (in the ear) By Report $20.00 By Report By Report By Report By Report By Report $1.00 By Report By Report By Report $ $ By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report * # = PA Required = Medical Justification or Written Report Required I-17 Hearing Aid Services Coverage and rates are subject to change Effective 1/11/2006 Dates of 7/31/2006 Service