Expedited Prior Authorization (EPA)

What is expedited prior authorization (EPA)? 

The EPA process is designed to eliminate the need for written authorization. The agency establishes authorization criteria and identifies these criteria with specific codes, enabling providers to create an EPA number using those codes.

The agency denies claims submitted without the appropriate diagnosis, procedure code, or service as indicated by the last three digits of the EPA number. The billing provider must document in the client’s file how the EPA criteria were met and make this information available to the agency upon request.

Note: When billing using a paper claim form, enter the EPA number in field 23, or when billing electronically enter the EPA number in the Authorization or Comments field. 

What documentation is required when requesting PA or ETR?

 For all requests for prior authorization, the following documentation is required: 

• A completed, TYPED General Information for Authorization form, HCA 13-835. This request form MUST be the initial page when you submit your request.
•  A completed Hearing Aid Authorization Request form, 13-772, and all the documentation listed on this form and any other medical justification. 

Payment

What is included in the agency’s payment for hearing aids?

The agency’s payment for purchased hearing aids includes all the following:

•  A prefitting evaluation 
•  An ear mold 
•  A minimum of three post-fitting consultations 

The agency denies payment for hearing aids and/or services when claims are submitted without the prior authorization number, when required, or the appropriate diagnosis or procedure code(s). 

The agency does not pay for hearing aid charges paid by insurance or other payer source.

Note: To receive payment, the provider must keep documentation in the client's medical file to support the medical necessity for the specific make and model of the hearing aid ordered for the client. This documentation must include the record of the audiology testing providing evidence that the client's hearing loss meets the eligibility criteria for a hearing aid.

Billing and Claim Forms 

What are the general billing requirements?

• The time limits for submitting and resubmitting claims and adjustments. 
• How to bill for services provided to primary care case management (PCCM) clients. 
• How to bill for clients eligible for both Medicare and Medicaid. 
• How to handle third-party liability claims. 
• What standards to use for record keeping. 

What records must be kept in the client’s file?

This includes, but is not limited to, the following tests: 

• Audiogram results/graphs/tracings (including air conduction and bone conduction comparisons) 
• Basic or simple hearing tests or screening, such as is done in many schools 
• Tympanogram
•  Auditory brainstem response (ABR) 
• Electronystagmogram (ENG) (not a hearing test but a special test of inner ear balance)

A valid prescription from an audiologist for replacement batteries must be kept in the client’s chart.