Policy and Procedures For Audiology Services E-211

E-211 Prior Approval Process

Prior to the provision of certain services, approval must be obtained from the Department. If charges are submitted for services that require prior approval and approval was not obtained, payment will not be made for services as billed.

The Department will not give prior approval for an item or service if a less expensive item or service is considered appropriate to meet the patient's need.

Prior approval to provide services does not include any determination of the patient's eligibility. When prior approval is given, it is the provider's responsibility to verify the patient's eligibility on the date of service.

If a participant becomes enrolled in an MCO or MCCN during a period of time for which a prior approval has been previously granted, the prior approval will no longer be applicable, effective with the participant’s managed care enrollment date. Prior approval requests for participants in an MCO or MCCN should be directed to the individual plan.

E-211.1 Prior Approval Requests 

Prior approval requests must contain enough information for Department staff to make a decision on medical necessity, appropriateness and anticipated patient benefits of the service.

The single most common reason for denial of prior approval requests is lack of adequate information upon which to make an informed decision.

The following items or services may be provided only with prior approval by the Department:

• Binaural and/or monaural hearing aids and dispensing fees, if replacement is within three years of the initial or previous purchase.

• Quantity limits are exceeded.

• Supplies/Accessories not elsewhere classified.

A prior approval request to provide hearing aids must be accompanied by the following:

• A copy of a Practitioner’s order, signed by the practitioner and dated within the past twelve months, to allow the hearing aids to be fitted.

• The audiogram with the written recommendation.

• Documentation that reflects the actual acquisition cost of the hearing aid(s) or supplier’s catalog price confirming acquisition costs.

E-211.2 Approval of Service

If the service requested is approved, the provider and the patient will be mailed a computer-generated letter, Form HFS 3076, Prior Approval Notification, listing the approved services. Upon receipt of the Prior Approval Notification and delivery of the items, the items may be billed.

Any changes/corrections needed to the prior approval notification HFS 3076, mus  be submitted as a review via mail or fax with supporting documentation to the prior approval unit. The prior approval fax line to receive reviews is 217-558-4359.

E-211.3 Denial of Service

If the service requested is denied, a computer-generated Form HFS 3076, citing the denial reason, will be sent to the patient and the provider. The provider cannot file an appeal of the denial. If the provider obtains additional information that could result in a reversal of the denial, the provider may submit a new prior approval request with the supporting medical information attached.

E-211.4 Timelines

The Department is obligated to make a decision on hearing aid prior approval requests within thirty (30) days of receipt of a properly completed request, with exceptions as described in Topic E-211.5. If a decision has not been made within the thirty (30) day period, the service is automatically approved. If a service has been automatically approved, reimbursement will be made at the provider’s charge or the Department’s maximum rate, whichever is less.

If the request is incomplete or requires further information to be properly considered, the Department may request additional information from either the supplying provider or the practitioner who ordered the service. If additional information is requested within fourteen (14) days of receipt of the prior approval request, the thirty (30) day period stops. When the required information is received, a new thirty (30) day period begins. An HFS 3701 will be generated when additional information is required.

The provider can request status of a prior approval after thirty (30) days from the Department’s receipt date. 

This can be done by calling the prior approval unit at 1-877-782-5565, Option 5.

E-211.5 Post Approvals

Post approval may be requested. Post approval may be granted upon consideration of individual circumstances, such as:

• Determination of the patient’s eligibility for the Medical Assistance Program or for All Kids was delayed or approval of the application had not been issued as of the date of service. In such a case, the post approval request must be received no later than ninety (90) days following the Department’s Notice of Decision approving the patient’s application.

• There was a reasonable expectation that other third party resources would cover the item and those third parties denied payment after the item was supplied. To be considered under this exception, documentation that the provider billed a third party payor within six months following the date of service, as well as a copy of the denial from that third party must be supplied with the request for approval. The request for post approval must be received no later than ninety (90) days from the date of final adjudication by the third party.

• The patient did not inform the provider of his or her eligibility for Medical Assistance or All Kids. In such a case, the post approval request must be received no later than six months following the date of service to be considered for payment. To be considered under this exception, documentation of the provider’s dated, private-pay bills or collection correspondence, that were addressed and mailed to the patient each month following the date of service, must be supplied with the request for approval.

To be eligible for post approval consideration, all the normal requirements for prior approval must be met and post approval requests must be received by the Department no later than ninety (90) days from the date services or items are provided or within the time frames identified above.