Billing and Claim Forms (DDA Clients)

What are the general billing requirements? 

These billing requirements include: 

• The time limits for submitting and resubmitting claims and adjustments. 
• 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 those done in 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.

How do I complete the CMS-1500 claim form?

The following CMS-1500 claim form instructions relate to the Hearing Hardware program.

Field No :  23

Name : Prior Authorization Number 

Field Required : Yes

Entry : Use the social services authorization number assigned to you.

Field No :  24D

Name : Procedures, Services or Supplies CPT/HCPCS

Field Required : Yes

Entry : Enter the appropriate Current Procedural Terminology (CPT) or Common Procedure Coding System (HCPCS) procedure code for the services being billed. 

Modifier: When appropriate enter a modifier.

Authorization (DDA Clients)

What is a social services authorization?

 A social services authorization is administration approval for certain services, equipment, or supplies before the services are provided to clients as a precondition for provider payment.

How do I request a social services authorization? 

The client or the client’s representative initiates the request for a social services authorization. The provider can assist the client or representative in requesting a social services authorization by providing the following information: 

•  What equipment is necessary. 
•  An estimate of the total cost of all equipment requested. 
•  How the hearing hardware will assist the client to perceive, control, or communicate with the environment in which they live or to increase their abilities to perform activities of daily living. 
•  How the ancillary supplies or equipment will support proper functioning and continued use of the equipment, if the needed equipment supports the continued functioning of equipment the client already uses.

How do I view a social services authorization? 

The social services authorization can be viewed in ProviderOne. If you have questions about the social services authorization, contact the case manager listed on the authorization. 

What happens after the social services authorization is approved?

When the social services authorization is approved, the case manager will authorize using a blanket code SA893. The authorization will be for one unit at the estimated total cost. The provider will then submit the claim using the detailed procedure codes.

Payment (DDA Clients)

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

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

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

The administration denies payment for hearing aids and services when claims are submitted without the social services authorization number when required or the appropriate diagnosis or procedure code.

The administration 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.

Cochlear implant – replacement parts

The administration covers: 

•  Cochlear implant external speech processors, including maintenance, repair, and batteries. 
•  Baha® speech processors, including maintenance, repair, and batteries.

The administration pays for cochlear implant and Baha® replacement parts when: 

•  The manufacturer's warranty has expired. 
•  The part is for immediate use, not a back-up part. 
• The part needs to be replaced due to normal wear and tear and is not related to misuse or abuse of the item 

When reimbursing for battery packs, the administration covers the least costly, equally effective product.

What is not covered?

The administration does not cover the following hearing and hearing aid-related items and services for clients age 21 and older:

•  Tinnitus maskers 
•  Group screenings for hearing loss

Note: Reimbursement for all hearing instruments dispensed includes: 

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

Legend 

Modifiers: RA = Replacement of DME Item 

RB = Replacement Part of DME Item 

LT = Left 

RT = Right 

RR = Rental

Blanket Code	HCPCS Code	Short Description
SA893	L7510	Prosthetic device repair rep
SA893	L8615	Coch implant headset replace
SA893	L8616	Coch implant microphone repl
SA893	L8617	Coch implant trans coil repl
SA893	L8618	Coch implant tran cable repl
SA893	L8619	Coch imp ext proc/contr rplc
SA893	L8621	Repl zinc air battery
SA893	L8622	Repl alkaline battery
SA893	L8623	Lith ion batt CID,non-earlvl
SA893	L8624	Lith ion batt CID, ear level
SA893	L8627	CID ext speech process repl
SA893	L8628	CID ext controller repl
SA893	L8629	CID transmit coil and cable
SA893	L8691	Osseointegrated snd proc rpl
SA893	L8692	Non-osseointegrated snd proc
SA893	L8693	Auditory osseointegrated device abutment, replacement only
SA893	L9900	O&P supply/accessory/service

CMS-1500 claim form

How do I complete the CMS-1500 claim form?

The following CMS-1500 claim form instructions relate to the Hearing Hardware program. 

Field No: 19

Name : Reserved for Local Use

Field Required : When applicable

Entry : 

Enter: 

• “SCI=B” (Baby on parent’s ProviderOne Client ID); or 
•  Claim notes.

Field No: 23

Name : Prior Authorization Number

Field Required : When applicable

Entry : Use the prior authorization number assigned to you if/when services have been denied and you are requesting an exception to rule.

Field No: 24D

Name :  Procedures, Services or Supplies CPT/HCPCS

Field Required : Yes

Entry : Enter the appropriate Current Procedural Terminology (CPT) or Common Procedure Coding System (HCPCS) procedure code for the services being billed. Modifier: 

When appropriate enter a modifier.

Client Eligibility (DDA Clients) Developmental Disabilities Administration [DDA]

How can I verify a client’s eligibility? 

Providers must verify that a patient has a valid social services authorization for the date of service and that the client’s benefit package covers the applicable service. This helps prevent delivering a service the administration will not pay for. Providers can verify that a client has a valid social services authorization in ProviderOne. 

How do I view a social services authorization in ProviderOne?

Providers will receive an alert message when a social services authorization has been created or changed. To view the social services authorization from the provider portal: 

1. Select Social Services View Authorization List. The Provider Authorization List Page will appear. 2. Enter the authorization number from the alert or search by the Client ID. 

For questions about the authorization, contact the case manager listed on the alert.

Monaural or binaural hearing aids 

The administration covers new, non-refurbished, monaural or binaural hearing aids, which includes the ear mold and batteries, for clients eligible for the service. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs necessary as a result of the individual’s disability and be under warranty for a minimum of one year. 

Replacement 

The administration pays for the following replacements when approved with a social services authorization: 

• Hearing aids, which includes the ear mold, when all warranties are expired and the hearing aids are one of the following: 
• Lost 
• Beyond repair 
• Not sufficient for the client's hearing loss 
• Ear molds when the client's existing ear mold is damaged or no longer fits the client's ear. 
• Batteries with a valid prescription from an audiologist. 

Repair 

The administration pays for repair when approved with a social services authorization. To receive payment, all the following must be met: 

• All warranties are expired. 
• The repair is under warranty for a minimum of 90 days.

Rental 

The administration pays for a rental hearing aid for up to two months while the client's own hearing aid is being repaired. In the case of a rental hearing aid, the agency pays separately for an ear mold. 

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.