What is not covered?

The agency does not cover the following hearing and hearing aid-related items and services for clients age 20 and younger:

• Tinnitus maskers 
• Group screenings for hearing loss, except as provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program (refer to the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Billing Guide) 
• FM systems, including the computer-aided hearing devices for FM systems 

When EPSDT applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental. 

Exception to Rule (ETR) 

The agency evaluates a request for medical services, equipment, and/or supplies that are listed as noncovered under the provisions of WAC 182-501-0160 that relates to noncovered services. The request for a noncovered medical service, equipment, or supply is called a “request for an exception to rule.” 

HCPCS

Code                Short Description                                     Policy

L7510              Prosthetic device repair rep                       PA

L8615             Coch implant headset replace                 EPA/PA

L8616             Coch implant microphone repl               EPA/PA

L8617             Coch implant trans coil repl                    EPA/PA

L8618             Coch implant tran cable repl                   EPA/PA

L8619             Coch imp ext proc/contr rplc                       PA

L8621              Repl zinc air battery                               EPA/PA

L8622              Repl alkaline battery                              EPA/PA

L8623              Lith ion batt CID,non-earlvl                  EPA/PA

L8624              Lith ion batt CID, ear level                    EPA/PA

L8627              CID ext speech process repl                       PA

L8628              CID ext controller repl                               PA

L8629              CID transmit coil and cable                        PA

L8691               Osseointegrated snd proc rpl                     PA

L8692                Non-osseointegrated snd proc                  PA

L8693            Auditory osseointegrated device abutment,

                           replacement only                                    PA

L9900                O&P supply/accessory/service               PA

Legend

EPA: Expedited Prior Authorization 

PA: Prior Authorization required

Authorization

What is prior authorization (PA)? 

PA is agency approval for certain medical services, equipment, or supplies, before the services are provided to clients, as a precondition for provider payment.

Does the agency require prior authorization for hearing hardware? (WAC 182-547-1000) 

No. Except for certain services specified in the Coverage table, PA is not required for clients age 20 and younger for hearing aids and services. Providers must send claims for clients age 20 and younger directly to the agency. Providers do not need to obtain authorization from the local Children with Special Health Care Needs (CSHCN) Coordinator. 

Note: The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169. (WAC 182-547-1000 (2)) 

Coverage

Monaural or binaural hearing aids

 The agency covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear mold and batteries, for eligible clients age 20 and younger. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs and be under warranty for a minimum of one year. 

Replacement 

The agency pays for the following replacements as long as the need for replacements is not due to the client’s carelessness, negligence, recklessness, or misuse in accordance with WAC 182- 501-0050(8): 

• Hearing aid(s), which includes the ear mold, when all warranties are expired and the hearing aid(s) are one of the following: 
• Lost 
• Beyond repair 
• Not sufficient for the client's hearing loss 
• Ear mold(s) 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 agency pays for a maximum of two repairs, per hearing aid, per year, when the repair is less than 50% of the cost of a new hearing aid. 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 agency pays for a rental hearing aid(s) for up to two months while the client's own hearing aid is being repaired. In the case of a rental hearing aid(s), the agency pays separately for an ear mold(s). 

Cochlear implant – replacement parts

The agency covers: 

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

Baha® speech processors, including maintenance, repair, and batteries. 

The agency 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 (see WAC 182-502-0160).

The client must pay for repairs to additional speech processors and parts. 

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

Note: The agency does not pay providers for repairs or replacements that are covered under the manufacturer’s warranty.

Replacement parts - EPA criteria 

The following expedited prior authorization (EPA) criteria must be met: 

• The cochlear implant or bone conduction (Baha®) is unilateral (bilateral requires PA). 
• The manufacturer’s warranty has expired. 
• The part is for immediate use (not a back-up part). 

Note: If the client does not meet the EPA criteria, then PA is required. 

Use EPA 870000001 with HCPCS codes L8615-L8618, L8621-L8624 when billing for cochlear implant and bone conduction (Baha®) replacement parts

Usual & customary fee

The rate that may be billed to the agency for a certain service or equipment. This rate may not exceed either of the following:

1) The usual and customary charge that you bill the general public for the same services 

2) If the general public is not served, the rate normally offered to other contractors for the same services

Client Eligibility

How can I verify a patient’s eligibility?

Providers must verify that a patient has Washington Apple Health coverage for the date of service, and that the client’s benefit package covers the applicable service. This helps prevent delivering a service the agency will not pay for.

 Verifying eligibility is a two-step process:

Step 1. Verify the patient’s eligibility for Washington Apple Health. For detailed instructions on verifying a patient’s eligibility for Washington Apple Health, see the Client Eligibility, Benefit Packages, and Coverage Limits section in the agency’s current ProviderOne Billing and Resource Guide. If the patient is eligible for Washington Apple Health, proceed to Step 2. If the patient is not eligible, see the note box below. 

Step 2. Verify service coverage under the Washington Apple Health client’s benefit package. To determine if the requested service is a covered benefit under the Washington Apple Health client’s benefit package, see the agency’s Program Benefit Packages and Scope of Services web page. 

Note: Patients who are not Washington Apple Health clients may submit an application for health care coverage in one of the following ways: 

1. By visiting the Washington Healthplanfinder’s website at: www.wahealthplanfinder.org 

2. By calling the Customer Support Center toll-free at: 855-WAFINDER (855-923-4633) or 855-627-9604 (TTY) 

3. By mailing the application to: Washington Healthplanfinder PO Box 946 Olympia, WA 98507 In-person application assistance is also available. 

To get information about inperson application assistance available in their area, people may visit www.wahealthplanfinder.org or call the Customer Support Center. 

Clients age 20 and younger who are receiving services under a Benefit Package:

Are eligible for the covered hearing aids and services listed in this billing guide and for the audiology services listed in the agency’s Physician-Related Services/Health Care Professional Services Billing Guide. 

 Must have a complete hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed by a hearing healthcare professional. 

Must be referred by a licensed audiologist, otorhinolaryngologist, or otologist for a hearing aid.

Hearing aids are covered under agency-contracted managed care organizations (MCO). Clients who are enrolled in an agency-contracted MCO are eligible for covered hearing aids. Bill the MCO directly for these services. Additionally, clients enrolled in an agency-contracted MCO must obtain replacement parts for cochlear implants and bone anchored hearing aids (Baha®), including batteries, through their MCO.

Apple Health Core Connections (AHCC)

Coordinated Care of Washington (CCW) will provide all physical health care (medical) benefits, lower-intensity outpatient mental health benefits, and care coordination for all Washington State foster care enrollees. These clients include: 

• Children and youth under the age of 21 who are in foster care 
• Children and youth under the age of 21 who are receiving adoption support 
• Young adults age 18 to 26 years old who age out of foster care on or after their 18th birthday

American Indian/Alaska Native (AI/AN) children will not be auto-enrolled, but may opt into CCW. All other eligible clients will be auto-enrolled.

AHCC complex mental health and substance use disorder services  

AHCC clients who live in Skamania or Clark County receive complex behavioral health benefits through the Behavioral Health Services Only (BHSO) program in the SW WA region. These clients will choose between CHPW or MHW for behavioral health services, or they will be autoenrolled into one of the two plans. CHPW and MHW will use the BHO Access to Care Standards to support determining appropriate level of care, and whether the services should be provided by the BHSO program or CCW.

AHCC clients who live outside Skamania or Clark County will receive complex mental health and substance use disorder services from the BHO and managed by DSHS.

Bone-anchored hearing aid (Baha) – A type of hearing aid based on bone conduction. It is primarily suited to people who have conductive hearing losses, unilateral hearing loss, and people with mixed hearing losses who cannot otherwise wear ‘in the ear’ or ‘behind the ear’ hearing aids. 

Cochlear implants - A cochlear implant is a small, complex electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin. 

Developmental Disabilities Administration (DDA) – A division administration within the Department of Social and Health Services. DDA provides services to children and adults with developmental disabilities. 

Digital hearing aids – Hearing aids that use a digital circuit to analyze and process sound. (WAC 182-547-0200)

Hearing aids - Wearable sound-amplifying devices that are intended to compensate for hearing loss. Hearing aids are described by where they are worn in the ear as in-the-ear (ITE), behind-the-ear (BTE), etc. Hearing aids can also be described by how they process the amplified signal. This would include analog conventional, analog programmable, digital conventional, and digital programmable. (WAC 182-547-0200) 

Hearing health care professional – An audiologist or hearing aid fitter/dispenser licensed 

 RCW, or an otorhinolaryngologist or otologist licensed

Maximum allowable fee - The maximum dollar amount that the agency will pay a provider for specific services, supplies, and equipment.

Prior authorization – A form of authorization used by the provider to obtain approval for a specific hearing aid and service(s). The approval is based on medical necessity and must be received before service(s) are provided to clients as a precondition for payment. (WAC 182-547-0200) 

Programmable hearing aids – Hearing aids that can be “programmed” digitally by a computer. All digital hearing aids are programmable, but not all programmable hearing aids are digital. 

Social Services Authorization – A form of authorization used by the Department of Social and Health Services to preauthorize services. The approval is based on medical necessity and client eligibility for the program or service. A Social Services Authorization can be viewed in ProviderOne.