E-202.4 Payment

Payment made by the Department for professional services and for hearing aid accessories, supplies and hearing aid repairs will be made at the lower of the provider’s usual and customary charge or the maximum rate as established by the Department.

Audiological services in a hospital are covered depending on the setting. Inpatient charges are included in the Department’s reimbursement to a hospital and are not to be billed fee for service. Outpatient services rendered by a salaried audiologist may be billed fee for service by the hospital. If a salaried audiologist is enrolled, the audiologist may bill fee for service. In no circumstance, should the audiologist and the hospital bill for the same service.

E-202.5 Fee Schedule 

A fee schedule of allowable procedure codes by provider type is available on the Department’s website. 

For DME providers and audiologists who provide hearing aids and hearing aid supplies, there is a listing by HCPCS code. The DME fee schedule lists the maximum rates, quantity limitation, whether the item is covered for residents of Long Term Care facilities and prior approval requirements for each item. For an audiologist’s professional services there is an Audiology fee schedule which lists CPT codes used for diagnostic testing. 

Providers will be advised of major changes via an electronic notice. Providers should sign up to receive electronic notification of new releases on the Department’s website. Please mark “All Medical Assistance Providers” as well as each specific provider type for which notification is requested. 

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.