Download Section 23 - Hearing Aid and Audiometric Evaluations

Section
23
Hearing Aid and Audiometric
Evaluations
23
23.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.1.1 Medicaid Managed Care Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3 Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1 Hearing Screenings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1.1 Newborn Hearing Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1.2 Initial Test at Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1.3 Outpatient Hearing Screening and Diagnostic Testing for Children . . . . .
23.3.1.4 Three Years of Age and Younger . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1.5 Three Through 20 Years of Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1.6 Abnormal Screening Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.1.7 Adults Hearing Screening 21 Years of Age and Older . . . . . . . . . . . . . .
23.3.1.8 Hearing Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.2 Hearing Aid Instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.2.1 Warranty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.2.2 30-Day Trial Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.2.3 Fitting and Dispensing Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.2.4 First Revisit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.2.5 Second Revisit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.3.3 Audiological Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.4 Limitations and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.5 Documentation Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.6 Client Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.7 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23.7.1 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Section 23
23.1 Enrollment
To enroll in the Texas Medicaid Program, hearing aid
professionals (physicians, audiologists, and fitters and
dispensers) who provide hearing evaluations or fitting and
dispensing services must be licensed by the licensing
board of their profession to practice in the state where the
service is performed. Hearing aid providers are only
eligible to enroll as individuals and facilities. Additionally,
audiologists not wanting to enroll as a hearing aid provider
are allowed to enroll separately as audiologists.
Providers cannot be enrolled if their license is due to
expire within 30 days. A current license must be
submitted.
Important: All providers are required to read and comply
with Section 1, Provider Enrollment and Responsibilities.
In addition to required compliance with all requirements
specific to the Texas Medicaid Program, it is a violation of
Texas Medicaid Program rules when a provider fails to
provide health-care services or items to Medicaid clients
in accordance with accepted medical community
standards and standards that govern occupations, as
explained in Title 1 Texas Administrative Code (TAC)
§371.1617(a)(6)(A). Accordingly, in addition to being
subject to sanctions for failure to comply with the requirements that are specific to the Texas Medicaid Program,
providers can also be subject to Texas Medicaid Program
sanctions for failure, at all times, to deliver health-care
items and services to Medicaid clients in full accordance
with all applicable licensure and certification requirements
including, without limitation, those related to documentation and record maintenance.
appeal, and must include an invoice validating the cost of
the instrument. The maximum allowable fee for the
hearing aid instrument includes:
• Acquisition cost of the hearing aid (the actual cost or
net cost of the hearing aid after any discounts have
been deducted).
• Manufacturer’s postage and handling charges.
• All necessary tubing, cords, and connectors.
• Bone conduction headbands.
• Telephone coils.
• Compression circuits.
• Contralateral Routing of Offside Signal
(CROS)/Bilateral Contralateral Routing of Offside
Signal (BICROS) features.
• Instructions for care and use.
• One-month supply of batteries.
Charges for hearing aid components must be verified by
the manufacturer’s invoice and price lists. The fitting and
dispensing fee includes the postfitting check of the
hearing aid within five weeks after the dispensing date.
Note: Charges to the client for covered services constitute
a breach of the Medicaid contract.
Refer to: “Reimbursement Methodology” on page 2-2 for
more information on reimbursement.
“Billing Clients” on page 1-10 for more
information.
Fee schedules for services in this chapter are available on
the TMHP website at www.tmhp.com/file library
/file library/fee schedules.
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Refer to: “Provider Enrollment” on page 1-2 for more
information on enrollment procedures.
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23.1.1 Medicaid Managed Care Enrollment
23.3 Benefits
Hearing aid providers must enroll with Medicaid Managed
Care to be reimbursed for services provided to Medicaid
Managed Care clients.
Hearing aid services, including hearing aid instruments,
are considered for reimbursement when they are
medically necessary. Benefits for hearing aid services are
determined by statutory and fiscal limitations.
23.2 Reimbursement
Hearing aids and audiometric services are reimbursed in
accordance with 1 TAC §355.8141. Hearing evaluations
and the first and second revisits are reimbursed according
to the maximum allowable fee. Procedure codes R-99211
and R-99212 should be billed for the first and second
revisits, respectively.
Reimbursement for ear molds and the fitting and
dispensing fee is limited to the established maximum fee.
Hearing aid procedures indicated with "MR" (Manually
Review) must be submitted with the Manufacturer's
Suggested Retail Price (MSRP) in the Comments field of
the claim. If the MSRP is not included in the comments
field on the original submission, the claim will be denied.
Providers will be required to submit their request as an
23–2
For clients 21 years of age and older, hearing aid services
are benefits of the Texas Medicaid Program.
For Medicaid clients 20 years of age and younger, hearing
aid services are available through the Department of State
Health Services (DSHS) Program for Amplification for
Children of Texas (PACT).
An appropriate hearing screening is a mandatory part of
each medical check up. When suspicion or indication of a
hearing problem occurs, the client should be referred to
an enrolled PACT provider. For a list of PACT providers,
visit the PACT website at www.dshs.state.tx.us/audio
/program.shtm or write to:
DSHS
Program for Amplification for Children of Texas (PACT)
1100 West 49th Street
Austin, TX 78756-3199
1-512-458-7724
CPT only copyright 2007 American Medical Association. All rights reserved.
Hearing Aid and Audiometric Evaluations
23.3.1 Hearing Screenings
Audiometry is the testing of a person’s ability to hear
various sound frequencies and is performed with the use
of electronic equipment. Audiometry is used to identify
and diagnose hearing loss. Otoacoustic emissions (OAE)
or auditory brainstem response (ABR) audiometry are
benefits of the Texas Medicaid Program for infants,
children, and adults who cannot be tested by conventional
audiometry.
23.3.1.1 Newborn Hearing Screening
Health Safety Code, Chapter 47, Vernon’s Texas Codes
Annotated mandates that a newborn hearing screening
occur at the birthing facility before hospital discharge. The
hospital is responsible for the purchase of equipment,
training of personnel, screening of the newborns, certification of the program according to DSHS standards, and
notification to the provider, parents, and DSHS of
screening results.
OAE or ABR audiometry are used to screen for newborn
hearing and may be performed as early as a few hours
after birth when completed by a licensed audiologist.
There is no additional Medicaid reimbursement for the
newborn hearing screening because the procedure is part
of the newborn hospital diagnosis related group (DRG)
payment. Hospitals must use procedure code K-09547 to
report this newborn hearing screen on the UB-04
CMS-1450 claim form.
This facility-based screening also meets the physician’s
required component for hearing screening in the inpatient
newborn Texas Health Steps (THSteps) check up. The
physician must ensure that the hearing screening is
completed before discharging the newborn or, when the
birthing facility is exempt under the law, that there is an
appropriate referral for a hearing screening to a birthing
facility participating in the newborn hearing screening
program.
The physician must discuss the screening results with the
parents, especially if the hearing screening results are
abnormal, and order an appropriate referral for further
diagnostic testing. If the results are abnormal, the
parent’s or legal guardian’s consent must be obtained to
send information to DSHS for tracking and follow-up
purposes.
If a physician has any concerns about this process, the
physician should contact the hospital administrator or the
DSHS Audiology Services Program at 1-512-458-7724.
23.3.1.2 Initial Test at Birth
The provider must do the following:
• Verify that the parents received the results of the
hearing screen at the birthing facility.
• Check for obvious physical abnormalities.
• Provide a referral for further diagnostic audiological
testing for an infant with abnormal screening results or
who is at high-risk for hearing impairment.
If the Infant is admitted to a birthing facility, the facility
where the birth occurs must offer newborn hearing
screenings through a program mandated by the Texas
State Legislature and certified by the Texas Department of
Health.
Procedures for newborn hearing screenings provided
during the birth admission are considered part of the
newborn delivery payment to the facility and are not
considered for reimbursement as separate procedures.
If the infant is not admitted to a birthing facility or is born
outside of a birthing facility, procedures for newborn
hearing screenings performed during the initial Texas
Health Steps (THSteps) visit are considered part of the
initial newborn medical check up and are not considered
for reimbursement as separate procedures. Providers that
are not THSteps-enrolled must refer the infant to an
enrolled THSteps provider for an initial THSteps medical
check up, which includes a newborn hearing screening.
An initial newborn hearing screening for infants who are
not admitted to a birthing facility consists of the following:
• Completing the Hearing Checklist for Parents form.
• Assessing any physical abnormalities.
• Instructing the parent(s) on the use of the hearing
checklist.
• Informing the parent(s) of the results.
• Referring the high-risk infant to a physician who renders
audiology services.
23.3.1.3 Outpatient Hearing Screening and
Diagnostic Testing for Children
As part of the THSteps medical check up, physicians are
required to complete the hearing screening component.
Separate procedure codes must not be billed when
hearing screenings are part of medical check ups or day
care/school requirements. Medicaid does not reimburse
separately.
For children who are seen in the office setting, THSteps
requires a puretone audiometer for visits where objective
screening is required. In other childcare settings (e.g., day
care; preschool; Head Start; and elementary, middle, and
high school), the DSHS Vision and Hearing Screening
Program requires that a puretone audiometer be used for
hearing screening.
Impedance testing is usually used in the physician’s office
to monitor children who have a documented history of
repeated bouts of otitis media and may be billed
separately as a diagnostic hearing test with a THSteps
check up. Impedance testing does not meet the requirements for the sensory screening component of the
THSteps check up.
• Supply a hearing checklist for parents and instructions
on its use (this checklist is discussed at the first inoffice THSteps medical check up).
CPT only copyright 2007 American Medical Association. All rights reserved.
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Section 23
23.3.1.4 Three Years of Age and Younger
A hearing screening must be completed during each
THSteps medical check up. A THSteps hearing screening
consists of the following:
• An observation and history recording obtained from a
responsible adult familiar with the child.
• Completion of the Hearing Checklist for Parents form.
• Referral of a high-risk child to a physician who renders
audiology services.
23.3.1.5 Three Through 20 Years of Age
For children 3 years through 20 years of age, physicians
are required to complete the hearing screening during
each THSteps medical check up as part of the check up.
Medicaid will not consider the hearing screening for
reimbursement separate from the check up. For children
who are seen in the office setting, the THSteps program
requires a pure tone audiometer at visits where objective
screening is required. In other child-care settings, (e.g.,
day care; preschool; Head Start; elementary, middle, and
high school), the TDH Vision and Hearing Screening
Program requires that a pure tone audiometer be used for
hearing screening. The provider should do the following:
• Assess children with a puretone audiometric hearing
screen (1000, 2000, 4000 Hz) at 4 through 10 years
of age.
• Perform a subjective hearing evaluation, to include
client history and observation of the child for the ability
to answer questions and follow directions at all other
medical check ups where an audiometric screen is not
required.
• Document the results of any school screening audiometric testing program in the 12 months preceding the
medical check up.
• Refer any child or adolescent (preschool through twelfth
grade) who does not respond to a 25 dB tone at any
frequency for a diagnostic hearing evaluation.
23.3.1.6 Abnormal Screening Results
All abnormal hearing screenings for infants and children
from 20 years of age and younger should be referred to a
local Medicaid provider for follow-up. If the purpose is to
determine permanent hearing loss or type of amplification
needed, infants and children must be referred to an
approved hearing services PACT provider for follow-up.
Traditional Medicaid providers may be reimbursed for the
follow-up care when a local PACT provider is not
accessible.
All abnormal hearing screenings for clients 21 years of
age and older must be referred to a physician who
provides audiological services.
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23.3.1.7 Adults Hearing Screening 21 Years of Age
and Older
ABR and OAE audiometry are benefits of the Texas
Medicaid Program for infants, children, and adults and
may be used in addition to conventional audiometry for
further diagnosis.
23.3.1.8 Hearing Referrals
For clients 20 years of age and younger, providers should
refer Medicaid-eligible children identified during the
THSteps medical check up as needing a diagnostic
hearing evaluation or other hearing services, including
hearing aids, to an approved hearing services provider.
DSHS provides payment to providers for hearing services
provided to children eligible for Texas Medicaid Program
services.
Separate procedure codes may be billed for children who
require diagnostic hearing testing. The following
diagnostic audiometric testing codes may be billed as
appropriate: 5/I-92567, 5/I/T-92585, 5-92586,
5/I/T-92587, and 5/I/T-92588.
23.3.2 Hearing Aid Instrument
Medicaid reimbursement for hearing aid instruments is
limited to eligible clients, 21 years of age and older,
whose air conduction puretone average in the better ear
is 45 dB or greater. The client must have medical
necessity for a hearing aid instrument and have no
medical contraindications for using a hearing aid. Each
client must be offered an appropriate new hearing aid
instrument within the Medicaid allowable fee schedule.
Hearing aid(s) are considered for reimbursement once
every six years.
Important: TMHP may refer people to the Texas Rehabilitation Commission whose jobs are contingent on
possession of a hearing aid as well as people appearing
to have vocational potential and who need a hearing aid.
23.3.2.1 Warranty
Each hearing aid instrument dispensed through the Texas
Medicaid Program must be a new and current model that
meets the performance specifications indicated by the
manufacturer and the client’s individual hearing needs. A
new hearing aid is one that has never been used and
carries a full 12-month manufacturer’s warranty. The
manufacturer’s warranty must be effective for 12 months
after the dispensing date.
23.3.2.2 30-Day Trial Period
Providers must allow each Medicaid client a 30-day trial
period that gives the client time to determine satisfaction
with a purchased hearing aid instrument. The trial period
consists of 30 consecutive days beginning with the
dispensing date. During the trial period, providers may
dispense additional hearing aids as medically necessary
until the client is satisfied with the results of the aid, or
the provider determines that the client cannot benefit
CPT only copyright 2007 American Medical Association. All rights reserved.
Hearing Aid and Audiometric Evaluations
from the dispensing of an additional hearing aid. A new
trial period begins with the dispensing date of each
hearing aid. Under the Texas Medicaid Program, if the
client is not satisfied with the purchased hearing aid
instrument, the client may return it to the provider, who
must accept it.
Procedure Code
Medicaid Fee
R-V5060
MR
R-V5070
MR
R-V5080
MR
R-V5090
$100.00
R-V5100
MR
R-V5110
$150.00
R-V5120
MR
R-V5130
MR
R-V5140
MR
R-V5150
MR
R-V5160
$170.00
R-V5170
MR
R-V5180
MR
R-V5190
MR
R-V5200
$170.00
R-V5210
MR
R-V5220
MR
R-V5230
MR
R-V5240
$170.00
23.3.2.5 Second Revisit
The second revisit procedure code 99212, includes aided
sound field testing performed by a contracted evaluator
according to the guidelines specified for the hearing evaluation. If the aided sound field test scores suggest a
decrease in hearing acuity, the provider must include
puretone and speech audiometry on Form 3503, Hearing
Aid Evaluation Report. The second revisit is available as
needed after the post-fitting check and the first revisit.
R-V5241
$115.00
R-V5242
MR
R-V5243
MR
R-V5244
MR
R-V5245
MR
R-V5246
MR
R-V5247
MR
The following table lists hearing aid instrument,
assessment, and revisit procedure codes.
R-V5248
MR
R-V5249
MR
R-V5250
MR
R-V5251
MR
R-V5252
MR
R-V5253
MR
R-V5254
MR
Medicaid Fee
R-V5255
MR
*
R-V5256
MR
R-99212
*
R-V5257
MR
R-V5010
$44.35
R-V5258
MR
R-V5011
$50.00
R-V5259
MR
R-V5030
MR
R-V5260
MR
R-V5040
MR
R-V5261
MR
R-V5050
MR
R-V5262
MR
If the aid is returned within 30 days, the provider may
charge the client a rental fee. Providers must obtain a
client-signed acknowledgment statement stating the
client is responsible for paying the hearing aid rental fees
and retain the signed acknowledgment statement in the
client’s file. Client must sign the acknowledgment
statement prior to receiving the hearing aid. Providers
must allow 30 days to elapse from the hearing aid
dispensing date before completing a 30-Day Trial Period
Certification Statement.
23.3.2.3 Fitting and Dispensing Visit
The fitting and dispensing visit also includes the postfitting check.
23.3.2.4 First Revisit
Additional counseling is available as needed within a
period of six months after the post-fitting check. The first
revisit, 99211, includes a hearing aid check.
Note: Hearing aid procedures indicated with "MR" must
be submitted with the MSRP in the Comments field of the
claim. If the MSRP is not included in the comments field
on the original submission, the claim will be denied.
Providers will be required to submit their request as an
appeal, and must include an invoice validating the cost of
the instrument.
Procedure Code
R-99211
* Refer to the Physician Fee Schedule on the TMHP
website at www.tmhp.com
CPT only copyright 2007 American Medical Association. All rights reserved.
23
* Refer to the Physician Fee Schedule on the TMHP
website at www.tmhp.com
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Section 23
Medicaid Fee
Procedure Code
R-V5263
MR
R-V5264
$18.90
R-V5265
$18.90
R-V5275
$18.90
R-V5298
MR
R-V5299
MR
* Refer to the Physician Fee Schedule on the TMHP
website at www.tmhp.com
patient’s medical record. Tympanometry does not meet
the requirements for a sensory screening component of
the THSteps medical check up.
Acoustic reflex testing (procedure codes 5-92568 and
5-92569) provides information about the middle ear,
specifically middle ear muscle reflexes in response to
sound. The test can help distinguish between sensory
(cochlear) hearing loss and neural (retro-cochlear) hearing
loss. Acoustic reflex testing (procedure codes 5-92568
and 5-92569) is limited to the following diagnosis codes:
Diagnosis Codes
2251
3510
3511
3518
3519
23.3.3 Audiological Testing
38600
38601
38602
38603
38604
Audiometry is the testing of a person’s ability to hear
various sound frequencies and is performed with the use
of electronic equipment. Audiometry is used to identify
and diagnose hearing loss.
38610
38611
38612
38619
3862
38630
38631
38632
38633
38634
38635
38640
38641
38642
38643
38648
38650
38651
38652
38653
38654
38655
38656
38658
3868
3869
3870
3871
3872
3878
3879
3882
38830
38831
38832
38840
38841
38842
38843
38844
38845
3885
38905
38906
38913
38915
38916
38917
38920
38921
38922
7443
7804
Air and bone pure tone audiometry threshold testing
assesses air and bone conduction. Speech reception
threshold (SRT) and word recognition tests indicate the
softest level that a person is able to hear and repeat
two-syllable words, and how well a person can repeat
words presented at a comfortable listening level. Speech
audiometry uses a series of simple recorded words
spoken at various volumes into headphones worn by the
person being tested. The person repeats each word back
as it is heard.
Procedure code 5-92557 is a comprehensive code. If any
of the following procedure codes are submitted with the
same date of service as procedure code 5-92557, they
are denied as part of another service:
Procedure Codes
5-92551
5-92552
5-92555
5-92556
5-92553
Evoked response testing includes the following
procedures:
• ABR, also called brainstem evoked potential (BSER),
audiometry is a procedure in which neural discharges
from the auditory pathways are measured with surface
electrodes situated on the scalp.
• Otoacoustic emissions (OAE) measures response from
the cochlea.
If three or more of the procedure codes listed above are
submitted for reimbursement with the same date of
service, they are denied with instructions to submit the
appropriate audiometry procedure code (5-92557).
Procedure codes 5-92585, 5-92586, 5/I/T-92587, and
5/I/T-92588 may be submitted for evoked response
testing.
Procedure codes 5-92563, 5-92567, 5-92568, and
5-92569 are diagnostic hearing procedures that may be
considered for reimbursement separately.
Each evoked potential test is considered a bilateral
procedure. If separate charges are submitted for left- and
right-sided tests of the same type, the tests will be
combined and considered a quantity of one.
Tympanometry impedance testing (procedure code
5-92567) should never be used as the sole clinical means
to establish the presence or absence of acute or chronic
middle ear effusion or infection. Direct otoscopic examination by a suitably qualified provider, with or without
pneumatic otoscopy, is the key element of the standard
method used to establish a diagnosis of middle ear
disease.
Tympanometry must be limited to selected individual
cases where its use demonstrably adds to the provider's
ability to establish a diagnosis and provide appropriate
treatment. Tympanometry is limited to four services per
year by the same provider and is based on medical
necessity. Medical necessity must be documented in the
23–6
An electroencephalogram (EEG) submitted with the same
date of service as an evoked response test is considered
for reimbursement at the full reimbursement rate. Evoked
response testing is also considered for reimbursement at
the full reimbursement rate.
Procedure code 1-95920 is considered for reimbursement
in addition to each evoked potential test. Procedure code
1-95920 is limited to a maximum of two hours each day,
regardless of provider, without documentation of medical
necessity.
CPT only copyright 2007 American Medical Association. All rights reserved.
Hearing Aid and Audiometric Evaluations
23.4 Limitations and Exclusions
23.6 Client Eligibility
The following limitations and exclusions apply:
The provider determines a client’s eligibility for hearing aid
services by any of the following:
• Reimbursement for a hearing aid instrument is limited
to eligible clients, 21 years of age and older, whose air
conduction puretone average in the better ear is 45 dB
or greater.
• Hearing aid purchases are limited to one every six years
with the exception of clients birth through 20 years of
age through PACT.
• Asking to see the client’s current Medicaid eligibility
form (possession of a current Medicaid eligibility form
with a check mark in the hearing aid box indicates the
client’s eligibility for the month).
• Using the Automated Inquiry System (AIS) to determine
eligibility for Medicaid and for a hearing aid.
• Clients birth through 20 years of age must be referred
to PACT.
• Verifying client eligibility on the TMHP website at
www.tmhp.com.
• Services for residents in nursing facilities (skilled
nursing facility [SNF], intermediate care facility [ICF], or
extended care facility [ECF]) must be ordered by the
attending physician. The order must be on the client’s
chart and state the condition necessitating hearing aid
services and must be signed by the attending
physician.
Important: AIS provides claim status, client eligibility,
benefit limitations, and current check amount.
• No payment is made for replacement of batteries or
cords.
• No payment is made for repairs or replacements of lost,
destroyed, or inappropriate hearing aids.
• No binaural fittings are available except in certain
documented cases of legally blind, hearing-impaired
clients who have no other available resources. This
information must be documented in the client’s file as
well as on the claim submitted for payment for hearing
aid services.
• U.S.-manufactured hearing aids must be considered
when the purchase price and quality are comparable to
those of foreign manufacturers.
• Home visit hearing evaluations and fittings are
permitted only with the physician’s written
recommendation.
• Auditory training, speech, reading, or other rehabilitative services are not included.
Refer to: “Eligibility Verification” on page 4-4.
23
“Automated Inquiry System (AIS)” on page -xiii
for instructions or contact TMHP Customer
Service at 1-800-925-9126.
23.7 Claims Information
Hearing aid services must be submitted to TMHP in an
approved electronic format or on the CMS-1500 claim
form. Providers may purchase CMS-1500 claim forms
from the vendor of their choice. TMHP does not supply the
forms.
When completing a CMS-1500 claim form, all required
information must be included on the claim, as information
is not keyed from attachments. Superbills, or itemized
statements, are not accepted as claim supplements.
Providers supplying hearing aids for STAR+PLUS Medicaid
Qualified Medicare beneficiary (MQMB) clients should
submit claims to TMHP, not the STAR+PLUS HMO for the
hearing aid.
Refer to: “TMHP Electronic Data Interchange (EDI)” on
page 3-1 for information on electronic claims
submissions.
Refer to: “CMS-1500 Claim Filing Instructions” on
page 5-22.
“Claims Filing” on page 5-1 for general information about claims filing.
23.5 Documentation Requirements
“CMS-1500 Claim Filing Instructions” on
page 5-22. Blocks that are not referenced are
not required for processing by TMHP and may be
left blank.
TMHP does not require prior authorization for hearing aids
and related procedures. Retain reported audiological and
medical information in the client’s file until requested. The
hearing evaluation must be recommended by a physician
(with written medical clearance) for the fitting of a hearing
aid by completing the Physician’s Examination Report. The
Hearing Aid Evaluation Report must include an audiometric assessment. This form must provide objective
documentation to support improved communication ability
with amplification.
Refer to: “Physician’s Examination Report” on page B-71.
“Hearing Evaluation, Fitting, and Dispensing
Report (Form 3503)” on page B-41.
CPT only copyright 2007 American Medical Association. All rights reserved.
23–7
Section 23
23.7.1 Claim Filing Resources
Refer to the following sections and/or forms when filing
claims:
Resource
Page Number
Automated Inquiry System (AIS)
xiii
TMHP Electronic Data Interchange
(EDI)
3-1
CMS-Claims Filing Instructions
Communication Guide
5-22
A-1
Hearing Evaluation, Fitting, and
Dispensing Report (Form 3503)
B-41
Physician’s Examiniation Report
B-71
Hearing Aid Assessments Claim
Example
D-15
Acronym Dictionary
23–8
F-1
CPT only copyright 2007 American Medical Association. All rights reserved.