E-203 Covered Services
A covered service is a service for which payment can be made by the Department in accordance with 89 Ill. Adm. Code 140.3.
Services and materials are covered only when provided in accordance with the limitations and requirements described in the individual topics within this handbook. Audiologists who bill the Department for payment must have in the patient file a referral from a practitioner, i.e., an otologist, otolaryngologist or the primary care physician, as applicable.
Any questions a provider may have about coverage of a particular service should be directed to the Department prior to provision of the service. Providers may call the Bureau of Professional and Ancillary Services at 1-877-782-5565. If services are to be provided to a participant enrolled in a Managed Care Entity (MCE) prior authorization and payment must be obtained from the MCE.
E-203.1 Audiologist
Audiologists are authorized to provide basic and advanced hearing tests, evaluation of auditory rehabilitation status related to cochlear implantation, vestibular tests, hearing aid related testing and evaluation, hearing aid counseling, hearing aid fitting, and the sale of the hearing aid itself. Coverage also includes provision of hearing aid accessories, replacement of parts, and repairs.
There are procedure codes for audiologists only which pertain to follow-up services after a cochlear implant. These codes are not to be used under any other circumstance and can be found on the audiology fee schedule.
An audiologist who sells and dispenses hearing aids in addition to providing professional audiology services is expected by the Department to adhere to statutes guaranteeing the patient’s freedom of choice of providers. The audiologist must instruct the patient that they may obtain a hearing aid from any enrolled provider who can supply the appropriate aid.
E-203.2 Non-Audiologist Businesses
DME providers may provide hearing aids and hearing aid-related services and items but not professional audiology services for which an audiologist’s academic credentials and licensing are required.
Certified hearing instrument dispensers are eligible to provide hearing aid fitting, sale of the hearing aid itself, hearing aid accessories, replacement parts and repairs.
E-203.3 Hearing Aids
Providers must charge the actual acquisition cost of the hearing aid. The actual acquisition cost is the actual payment by the supplier for the hearing aid, taking into account any discounts, rebates or bonuses. The full amount of the discount must be subtracted when calculating the actual acquisition cost. The amount of any rebates or bonuses must be prorated to all purchases on which the rebate or bonus was earned. The prorated share must be subtracted when calculating the acquisition cost of the hearing aid.
The date of service to be submitted when billing for a hearing aid is the date the hearing aid is dispensed, not the fabrication date. The participant must be eligible on the dispensing date for providers to receive reimbursement from the Department.
A dispensing fee may be billed at the time the hearing aid is dispensed to the patient. The dispensing fee includes, but is not limited to payment for fitting, followup visits, shipping fees and retail mark-up for the hearing aid.
Exception: HFS covers hearing aid batteries. Allowable quantities are listed on the fee schedule. Batteries are not covered for clients who reside in a Long Term Care (LTC) facility. It is the responsibility of the LTC facility to provide its residents with batteries as the cost of the hearing aid batteries are included in the payment made by the Department to the LTC facility.
Provision of a hearing aid, whether by an audiologist or a DME provider, must include a minimum one-year warranty at no expense to the Department. Repair costs covered by the warranty are not to be submitted to the Department for payment.
E-203.3.1 Hearing Aid Criteria
In order to be eligible for reimbursement from the Department for hearing aids, the following criteria must be met:
When testing is performed in an acoustically treated sound suite:
The hearing loss must be 20 decibels (dB) or greater at any two of the following frequencies: 500, 1000, 2000, 4000, 8000 Hertz (Hz),
or
The hearing loss must be 25 dB or greater at any one of 500, 1000, 2000 Hz. When testing is performed at a site other than an acoustically treated sound suite: The hearing loss must be 30 dB or greater at any two of the following frequencies: 500, 1000, 2000, 4000, 8000 Hz,
or
The hearing loss must be 35 dB or greater at any one of 500, 1000, 2000 Hz.
E-203.4 Early Intervention Services
Early Intervention (EI) services are covered for children up to the age of three years, who are eligible for Part C services under the Individuals with Disabilities Education Act and when those services are included in the child’s Individualized Family Service Plan.
Procedure codes for EI services must be billed to the EI Central Billing Office (CBO) for payment. In order to receive payment from the CBO, a provider must apply for and obtain an Early Intervention Credential, enroll as a provider with the CBO and have prior authorization to provide services.
• For credential and enrollment information, contact Provider Connections at 1-800-701-0995.
• For questions about the service authorization and billing processes, contact the Early Intervention CBO Cornerstone Call Center at 1-800-634-8540.
E-204 Non-Covered Services
Services for which medical necessity is not clearly established are not covered by the Department’s Medical Programs. Refer to 89 Ill. Adm. Code 140.6 for a general list of non-covered services.
In addition, the following services are excluded from coverage in the Department’s Medical Programs and payment cannot be made for the provision of these services:
• Routine periodic exams in the absence of an identified problem.
• Examination required for the determination of disability or incapacity. (Local Department of Human Services offices may request that such examinations be provided with payment authorized from non-medical funds. Audiologists are to follow specific billing instructions given when such a request is made.)
• Expenses associated with postage and handling for any items.
• Travel expenses to provide testing.
• Batteries in a long term care setting.
Note: No separate additional charge is to be made for freight, postage, delivery, instruction, fitting, adjustments or measurement, since these services are considered to be inclusive in a provider’s dispensing fee charge. These additional charges cannot be billed to the patient.
E-205 Record Requirements
The Department regards the maintenance of adequate medical records as essential for the delivery of quality medical care. In addition, providers should be aware that medical records are a key document for post payment audits.
In the absence of proper and complete medical records, no payment will be made and payments previously made will be recouped. Lack of records or falsification of records may also be cause for a referral to the appropriate law enforcement agency for further action.
Providers must maintain an office record for each patient. In group practices, partnerships, and other shared practices, one record must be kept with chronological entries by the individual provider rendering services.
The record maintained by the audiologist must include the essential details of the patient’s condition and of each service or item provided. Any services provided to a patient by the audiologist outside the audiologist’s office are to be documented in the medical record maintained in the audiologist’s office. All entries must include the date and must be legible. Records which are unsuitable because of illegibility or language may result in sanctions if an audit is conducted.
For patients who are in a nursing facility, the primary medical record indicating the patient’s condition, treatment, and services ordered and provided during the period of institutionalization may be maintained as a part of the of the facility chart; however, an abstract of the facility record, including diagnosis, treatment program, dates and times services were provided, must be maintained by the audiologist as an office record to show continuity of care.
In addition to record requirements discussed in the Handbook for Providers of Medical Services, Chapter 100, General Policy and Procedures, an audiologist’s records are to include the following information:
• A copy of the referral from the Practitioner (otologist, otolaryngologist, primary care physician, Advanced Practice Nurse or Physician Assistant).
• A copy of the manufacturer’s invoice with the patient’s name and hearing aid serial number.
• Hearing aid evaluation results.
• Diagnosis.
• Audiogram.
• Medical history relevant to audiology services.
• Dates services or items were provided.
• A copy of the manufacturer’s invoice for an ear mold, if applicable.
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