Eligible Providers
* Physicians may provide audiology services, but first must contact the fiscal agent to confirm their enrollment with an otolaryngology specialty.
* Certified audiologists are eligible to become Medical Assistance Program providers. o Audiologists must be registered with the Department of Regulatory Agencies in order to dispense hearing aids.
* Colorado Home Intervention Program (CHIP) facilitators must be credentialed by Health Care Programs for Children with Special Needs (HCP) administered by the Colorado Department of Public Health and Environment. CHIP facilitators are eligible to become Medical Assistance Program providers and need to enroll in the Colorado Medical Assistance Program.
Covered Audiology Benefits
Hearing benefits are limited to the minimum services required to meet the member's medical needs. As stated in Volume 8.280.06, medically necessary, or medical necessity, shall be defined as a Medical Assistance Program service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental, cognitive or developmental effects of an illness, injury, or disability; and for which there is no other equally effective or substantially less costly course of treatment suitable for the child's needs.
Hearing exams, speech therapy, diagnostic testing, surgeries, and related hospitalizations are regular benefits of the Medical Assistance Program. Claims must meet all requirements outlined in this manual.
Newborn Hearing Screening
The Colorado legislature passed House Bill 97-1095, which establishes hearing screenings for newborn infants [25-4-1004.7(VI)(b)]. Appropriate testing and identification of newborn infants with hearing loss makes early intervention and treatment possible and promotes the healthy development of children.
Hearing Conservation Program (HCP) Audiology Regional Coordinators provide consultation information, technical assistance, and referral services to families of children with special health care needs.
Newborn Hearing Screening Reimbursement Policy
1. For inpatient hospital deliveries, reimbursement for newborn hearing screening is included in the hospital DRG for the delivery. CPT/HCPCS codes for hearing screening cannot be billed for dates on or during the date span of the delivery hospital stay.
a. Hospitals have been given responsibility for newborn hearing testing; therefore, Medicaid will not provide reimbursement in addition to that i ncluded in the DRG rate for services rendered in the inpatient hospital setting, including newborn nurseries or NICU.
2. For freestanding birth center deliveries or home births, reimbursement for newborn hearing screening may be billed using CPT/HCPCS codes for hearing screening. These codes may be billed for dates on or during the same date span of the delivery.
3. Follow-up screening for newborns who fail their initial hearing screening may be billed using CPT/HCPCS codes. Follow-up screens may be billed only if they occur on dates of service outside of the date span for the delivery hospital admission.
Newborn hearing screenings are a Preventive Service, but that designation does not supersede the reimbursement policies listed above.
Cochlear Implants
1. Cochlear implants are covered for clients aged 12 months through 20 years under the following criteria:
a. Limited benefit from appropriately fitted binaural hearing aids (with different definitions of “limited benefit” for children four (4) years of age or younger and those older than four (4) years) and a three (3) to six (6) month hearing aid trial.
b. Bilateral hearing loss with unaided pure tone average thresholds of 70 dB or greater.
c. Minimal speech perception measured using recorded standardized stimuli -speech discrimination scores of 50-60% or below with optimal amplification at 1000, 2000 and 4000 Hz.
d. Family support and motivation to participate in a post-cochlear aural, auditory and speech language rehabilitation program.
e. Assessment by an audiologist and otolaryngologist experienced in cochlear implants.
f. Bi lateral and hybrid/Electric Acoustic Stimulation cochlear implantation considered on a case by case basis.
g. No medical contraindications.
h. Up-to-date-immunization status as determined by the Advisory Committee on Immunization Practices (ACIP) 2. Replacement component(s) of an existing cochlear implant is a benefit for all ages when the currently used component(s) is no longer functional and cannot be repaired.
Hearing Aids
Hearing aids are a covered benefit for members ages 20 and under and for adult members on the Supported Living Services (SLS) Waiver.
When billing for a pair of hearing aids, each individual hearing aid must be listed on a separate line on the claim form and must have the appropriate modifier noted to indicate the ear for which it is fitted. The “RT” modifier indicates the heari ng aid is for the right ear, and the “LT” modifier indicates it is for the left ear. Billing for two (2) units of a hearing aid, on the same line, without the appropriate modifier will result in a denial.
Hearing Aid Trial Rental Period
The Trial Rental Period is included in the purchase reimbursement for the hearing aid(s). Use the last day of the rental period as the date of service.
Hearing Aid Replacement
Hearing aids are expected to last 3 – 5 years. Replacement of a hearing aid is covered for members ages 20 and under. Hearing aids may be replaced when they no longer fit, have been lost or stolen, or the current hearing aid is no longer medically appropriate for the child.
Ear Molds
Reimbursement for ear molds is included in the dispensing fee (procedure code V5090) charged in conjunction with the hearing aid code. Ear molds are not independently reimbursable, and are not a covered benefit for noise reduction or swimming.
Softbands (including Bone Anchored Hearing Aids - BAHAs)
Softband hearing devices (including BAHAs) are a covered benefit for members ages 20 and under. All softband purchases require a PAR and must be accompanied by a signed letter from a physician documenting medical necessity.
In addition,claims must be submitted on the CMS 1500 paper claim form and include the invoice received for purchasing the item. The Colorado Medical Assistance Program reimburses softband devices using the following methodology: invoice cost + 10%. Please see the table below for a list of procedure codes covered for softband devices.
All Audiology PARs and revisions processed by the ColoradoPAR Program must be submitted through eQSuite®. Clinical information is required for a PAR review. When submitting PARs, please answer the clinical questions in eQSuite®, attach the relevant clinical documentation needed for determinations, and select “Medical” type from the drop-down menu. If “DME” is selected this will result in non-payment of the device.
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