Prior Authorization

Prior authorization is required for the following:

♦ A monaural hearing aid costing more than $650

♦ Binaural hearing aids costing more than $1,300 

♦ Replacement of a hearing aid in less than four years for members 21 years of age and older

♦ FM systems

The Request for Prior Authorization, form 470-0829, should be submitted with:

♦ Examiner Report of Need for a Hearing Aid, form 470-4767 

♦ Results of hearing tests 

♦ Member history and diagnosis 

♦ Date of purchase of the current hearing aid, if known, or the approximate age of the hearing aid 

♦ Whether the aid is covered under warranty, if less than one year old

♦ Reason for replacement

Payment will be approved for a monaural aid costing more than $650 and for binaural aids costing more than $1,300 for either of the following:

♦ Educational purposes when the member is participating in primary or secondary education or an academic program leading to a degree, and either:

 • An in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise

 • An in-office comparison of two aids, one of which is singlechannel, shows significantly improved audibility

♦ Vocational purposes when documentation submitted indicates the necessity such as varying amounts of background noise in the work environment and a need to converse in order to do the job, and either:

• An in-office comparison of an analog aid and a digital aid matched (+- 5 dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise

 • An in-office comparison of two aids, one of which is singlechannel, shows significantly improved audibility

The following hearing aid services are covered when provided by audiologists or hearing aid dispensers.

f. Repair

Repair of hearing aids resulting from conditions not covered under the manufacturer’s warranty are covered.

(1) Parts and Labor

♦ In-house repairs are reimbursed at the current fee schedule amount. The U5 modifier must be billed with V5014 for in-house repairs.

♦ Out-of-house repairs are reimbursed at the amount shown on the manufacturer’s invoice plus a service charge, when applicable..

(2) Service Charge

Payment is allowed for a service charge in addition to the charge for parts and labor for out-of-house repairs if it is the provider’s practice to make such a charge to the general public. Bill the usual, customary, and reasonable service charge. Procedure code V5014 should be billed.

When a service charge is billed, it is considered to include all service functions performed in connection with repair of the hearing aid, including necessary travel, “loaners,” or any other service or supplies. Therefore, no additional charge may be made to the member or to others.