Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-021 - Hearing Services Provider Manual Update #84

Current through Register Vol. 49, No. 6, June, 2024
Section IIHearing Services
202.200
Enrollment in the Title XVIII
			 (Medicare Program)
For beneficiaries who are eligible for Medicare and Medicaid,
				see Section
				I of this manual for additional
				coinsurance and deductible information. See Section
				III for instructions on filing
				joint Medicare/Medicaid claims.
204.000
The Hearing Services
			 Provider's Role in the Child Health Services (EPSDT)Program
The Arkansas Medical Assistance Program includes a Child Health
				Services (Early and Periodic Screening, Diagnosis and Treatment or EPSDT)
				Program for eligible individuals under age 21. The purpose of this program is
				to detect and treat health problems in their early stages.
I f you are a Child Health
				Services (EPSDT) provider, please refer to the Child Health Services (EPSDT)
				manual for additional information.
Hearing Services providers interested in the Child Health
				Services (EPSDT) Program should contact the Child Health Services (EPSDT)
				Office.
View or print the Child Health Services Office
				(EPSDT) contact information
.
Hearing Services providers must bill Child Health Services
				(EPSDT) on the DMS-694 claim form when billing on paper. If billing
				electronically, use the professional claim format. Current billing information
				must be obtained from the Child Health Services (EPSDT) provider manual.
				Ancillary charges, such as lab and X-ray, associated with Child Health Services
				(EPSDT) should be listed on the claim.
View a sample DMS-694
				form.
Any enrolled Arkansas Medicaid provider who provides services
				that are not covered by the Arkansas Medicaid Program to a participant in the
				Child Health Services (EPSDT) Program who has been referred for services as a
				result of an EPSDT screen will be reimbursed for the services provided they are
				medically necessary and permitted under Federal Medicaid regulations.
When a provider performs a Child Health Services (EPSDT) screen
				and refers the patient to another provider for services not covered by Arkansas
				Medicaid, the referring provider must give the beneficiary a prescription for
				the services. The prescription must indicate that the services being prescribed
				are due to a Child Health Services (EPSDT) screen. The beneficiary must present
				this prescription to the provider. The beneficiary may take this prescription
				to the provider of his or her choice. The prescription for services must then
				be retained in the beneficiary's medical record for audit purposes by the
				provider who provides the services. If the beneficiary is then referred to
				another provider, the same procedure must be followed. A provider who performs
				a Child Health Services (EPSDT) screen may also provide services resulting from
				the screen, if appropriate.
In order for the non-covered service to be eligible for
				Medicaid payment, the referral documentation must be available for
				review.
The prescription for services must be dated by the provider
				referring the patient. The prescription for the non-covered service is
				acceptable if services were prescribed and the prescription is dated within the
				applicable periodicity schedule, not to exceed a maximum of
				12-months.
211.000
Introduction
The Arkansas Medicaid Program is designed to assist eligible
				Medicaid beneficiaries in obtaining medical care within the guidelines
				specified in Section I of this manual.
212.000
Coverage
Arkansas Medicaid covers hearing services for eligible Medicaid
				beneficiaries underage 21 in the Child Health Services (EPSDT) Program when
				prescribed by a physician.
213.000
Scope
The Utilization Review Section of the Division of Medical
				Services is responsible for authorizing hearing aid services for eligible
				Medicaid beneficiaries under age 21. Services are provided as a result of a
				referral from the beneficiary's primary care physician (PCP). If the
				beneficiary is exempt from the PCP process, then the attending physician must
				make the referral. Licensed audiologists may provide vestibular testing, aural
				rehabilitation and aural habilitation services.
Prior to providing hearing aid services to an eligible Medicaid
				beneficiary, a medical clearance must be obtained from a physician. This
				clearance must indicate if there are any medical or surgical indications
				contrary to fitting the beneficiary with a hearing aid. An audiological exam
				must be made by a certified audiologist or a physician. Arkansas Medicaid will
				not reimburse for a hearing test performed by a State-licensed hearing aid
				dispenser unless the hearing aid dispenser is also a licensed physician or
				licensed audiologist. The hearing evaluation must include the audiologist's or
				physician's recommendations regarding the brand name and model of the hearing
				aid to be dispensed and the name of the Medicaid dealer the patient has chosen
				to provide the hearing aid. The cost of the hearing aid should be provided if
				available. The medical clearance and hearing evaluation and a copy of the
				audiogram must be forwarded to the Division of Medical Services Utilization
				Review (UR) Section and must reach the UR Section within 6 months from the date
				the above evaluations were performed.
View or print the
				Division of Medical Services Utilization Review Section contact
				information
.
After reviewing the medical clearance from the
				physician and the audiological evaluation from the audiologist or the
				physician, a letter of authorization is sent from the Utilization Review
				Section to the Medicaid provider dispensing the hearing aid.
Fitting and servicing the hearing aid is performed by a
				licensed dispenser. The dealer must submit his or her claim for payment to EDS
				with the charges and serial numbers of the aid dispensed. Please refer to
				Section 240.000 of this manual for
				billing instructions and procedure codes regarding hearing aids.
The beneficiary is entitled to three follow-up visits to the
				dealer who dispensed the aid for the purpose of learning proper operation and
				care of the aid. The Medicaid Program does not reimburse the provider an
				additional amount for these three visits.
214.000
Limitations and/or Exclusions
There is a one-year warranty period during which all necessary
				adjustments, parts and replacements to the transmitter and receiver are
				provided at no cost to the beneficiary or to the Medicaid Program. At the
				expiration of the warranty period, the dealer will be reimbursed at the lesser
				of 75% of charges billed to private patients or the Title XIX maximum charge
				allowed for necessary repairs and replacements.
Repairs and replacements to the transmitter or receiver of
				hearing aids not purchased through the Medicaid Program may be authorized in
				the same manner as aids purchased through the Program. Medicaid will make no
				reimbursement for this equipment during the one-year warranty period.
Replacements are not covered under the Medicaid Program
				one-year warranty period. Reimbursement is made by Medicaid at 68% of charges
				billed to private pay patients.
In cases of equipment abuse, no payment will be made by the
				Medicaid Program. The beneficiary (or parent or guardian) is encouraged to
				purchase hearing aid insurance from the dealer to cover the cost of repairs or
				replacements.
214.100
Extension of Benefits
The hearing services provider may request an extension of
				benefits by sending a letter to the Utilization Review Unit requesting prior
				authorization for additional services. The request must be accompanied by the
				Medicaid beneficiary's medical record.
View or print the
				Utilization Review Section contact information
.
Providers are encouraged to use Form DMS-686,
				Amplification/Assistive Technology Recommendation Form, to request hearing aid
				services that require approval. Providers are not required to use DMS-686.
				However, all the information contained in DMS-686 must be submitted in writing
				to the reviewer.
View or print form
				DMS-686.
242.100
Audiology Procedure Codes
Use the following procedure codes for audiological function
				tests.
CPT Codes
92506
92507
92508
92541
92542
92543
92544
92545
92551
92552
92553
92555
92556
92557
92559
92560
92561
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92586
92587
92588
92590
92591
92594
92595
92626
92627
92630
92633
Use the following procedure code for hearing screenings for
				beneficiaries under age 21 in the Child Health Services (EPSDT) Program.
HCPCS
Procedure
Code
Modifier
V5008
EP
242.110
Hearing Aid Procedure Codes
Use the following procedure codes for hearing aid equipment for
				beneficiaries under age 21 in the Child Health Services (EPSDT) Program.
				Medicaid covers up to 2 hearing aids per beneficiary each six-months. Hearing
				aid procedure codes may be billed electronically or on a paper claim
				form.
HCPCS Procedure Codes
V5014*
V5030
V5040
V5050
V5060
V5120
V5130
V5140
V5170
V5180
V5210
V5220
V5267**
V5299
*Repairs require prior authorization
				"Accessories