Hearing Aids

3. Hearing Aids

The hearing aid should be adequate for the member’s condition and a reasonable expenditure as well.

An invoice must be submitted with claims for monaural hearing aids with a submitted charge of $401 or more and binaural hearing aids with a submitted charge of $802 or more.

If a hearing aid is returned to the provider within the allowable period of time, the provider should return the aid to the manufacturer. Notify the IME Provider Services Unit of the situation. Include copies of claims and invoices, remittance statements, and any peer review documentation. An adjustment to the payment for the hearing aid will be made.

a. Binaural Amplification

Binaural amplification is covered when suitable for bilateral hearing loss. Examples include:

♦ The aid is for a blind person

♦ The aid is needed for educational or vocational purposes 

♦ Lack of binaural amplification poses a hazard to a member’s safety 

♦ The member’s hearing loss has caused marked restriction of daily activities and constriction of interests, resulting in seriously impaired ability to relate to other people

The member record must document the reason for binaural hearing aids.

b. Dispensing Service

A dispensing service is covered to allow for the fitting and adjustment of the hearing aid when one is provided. It is considered to include follow up services for the first six months after the aid is provided.

When the member is unable to travel to the provider’s business due to medical reasons, the U-3 modifier should be used. Dispensing fees should be billed as follows:

Procedure                      Code Description 

V5241                       Monaural hearing aid 

V5241-U3                 Monaural hearing aid, nursing home 

V5160                       Binaural hearing aids 

V5160-U3                 Binaural hearing aids, nursing home 

When binaural hearing aids are appropriate but the member prefers to receive only one hearing aid initially and later returns for the second aid for binaural hearing, the monaural dispensing code should be billed for each hearing aid.

c. Ear Molds, Replacement

Payment for a service charge in addition to the cost of material for ear molds is allowed if it is the provider’s practice to make such a service charge to the general public. 

When a service charge is made, it is considered to include all functions performed in connection with fitting of the ear mold, including travel, if necessary. Therefore, no additional charge may be made to the member or others for the service.

d. Maintenance Items

Maintenance items, such as batteries, cords, and dry storage devices are payable when obtained from a participating provider. An invoice must be included with claims with a submitted charge of $51 or more.

Dispensing of hearing aid batteries is considered a service and must be documented in the member’s chart with the date of service and number of batteries dispensed. Up to 30 hearing aid batteries are covered within a 90-day period for a member with a monaural hearing aid. Up to 60 hearing aid batteries are covered within a 90-day period for a member with binaural hearing aids.

e. 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

Hearing Aids

The hearing aid should be adequate for the member’s condition and a reasonable expenditure as well.

An invoice must be submitted with claims for monaural hearing aids with a submitted charge of $401 or more and binaural hearing aids with a submitted charge of $802 or more.

If a hearing aid is returned to the provider within the allowable period of time, the provider should return the aid to the manufacturer. Notify the IME Provider Services Unit of the situation. Include copies of claims and invoices, remittance statements, and any peer review documentation. An adjustment to the payment for the hearing aid will be made.

a. Binaural Amplification

Binaural amplification is covered when suitable for bilateral hearing loss. Examples include:

♦ The aid is for a blind person 

♦ The aid is needed for educational or vocational purposes 

♦ Lack of binaural amplification poses a hazard to a member’s safety 

♦ The member’s hearing loss has caused marked restriction of daily activities and constriction of interests, resulting in seriously impaired ability to relate to other people

The member record must document the reason for binaural hearing aids.

b. Dispensing Service

A dispensing service is covered to allow for the fitting and adjustment of the hearing aid when one is provided. It is considered to include follow up services for the first six months after the aid is provided.

When the member is unable to travel to the provider’s business due to medical reasons, the U-3 modifier should be used. Dispensing fees should be billed as follows:

Procedure Code               Description 

V5241                    Monaural hearing aid

 V5241-U3          Monaural hearing aid, nursing home 

V5160                  Binaural hearing aids 

V5160-U3            Binaural hearing aids, nursing home 

When binaural hearing aids are appropriate but the member prefers to receive only one hearing aid initially and later returns for the second aid for binaural hearing, the monaural dispensing code should be billed for each hearing aid.

c. Ear Molds, Replacement

Payment for a service charge in addition to the cost of material for ear molds is allowed if it is the provider’s practice to make such a service charge to the general public.

 When a service charge is made, it is considered to include all functions performed in connection with fitting of the ear mold, including travel, if necessary. Therefore, no additional charge may be made to the member or others for the service.

d. Maintenance Items

Maintenance items, such as batteries, cords, and dry storage devices are payable when obtained from a participating provider. An invoice must be included with claims with a submitted charge of $51 or more.

 Dispensing of hearing aid batteries is considered a service and must be documented in the member’s chart with the date of service and number of batteries dispensed. Up to 30 hearing aid batteries are covered within a 90-day period for a member with a monaural hearing aid. Up to 60 hearing aid batteries are covered within a 90-day period for a member with binaural hearing aids.

Hearing Aids

Hearing aids are a covered benefit for members ages 20 and under and for adult members on the Supported Living Services (SLS) Waiver.

When billing for a pair of hearing aids, each individual hearing aid must be listed on a separate line on the claim form and must have the appropriate modifier noted to indicate the ear for which it is fitted. The “RT” modifier indicates the hearing aid is for the right ear, and the “LT” modifier indicates it is for the left ear. Billing for two (2) units of a hearing aid, on the same line, without the appropriate modifier will result in a denial.

Hearing Aid Trial Rental Period 

The Trial Rental Period is included in the purchase reimbursement for the hearing aid(s). Use the last day of the rental period as the date of service.

 Hearing Aid Replacement 

Hearing aids are expected to last 3 – 5 years. Replacement of a hearing aid is covered for members ages 20 and under. Hearing aids may be replaced when they no longer fit, have been lost or stolen, or the current hearing aid is no longer medically appropriate for the child. 

Ear Molds

Reimbursement for ear molds is included in the dispensing fee (procedure code V5090) charged in conjunction with the hearing aid code. Ear molds are not independently reimbursable, and are not a covered benefit for noise reduction or swimming. 

Softbands (including Bone Anchored Hearing Aids - BAHAs) 

Softband hearing devices (including BAHAs) are a covered benefit for members ages 20 and under. All softband purchases require a PAR and must be accompanied by a signed letter from a physician documenting medical necessity. In addition, claims must be submitted on the CMS 1500 paper claim form and include the invoice received for purchasing the item. The Colorado Medical Assistance Program reimburses softband devices using the following methodology: invoice cost + 10%. Please see the table below for a list of procedure codes covered for softband devices. 

All Audiology PARs and revisions processed by the ColoradoPAR Program must be submitted through eQSuite®. Clinical information is required for a PAR review. When submitting PARs, please answer the clinical questions in eQSuite®, attach the relevant clinical documentation needed for determinations, and select “Medical” type from the drop-down menu. If “DME” is selected this will result in non-payment of the device.