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. 

Reimbursement

E-202

When billing for services or materials, the claim submitted for payment must include a diagnosis and the coding must reflect the actual services provided or materials dispensed. Any payment received from a third-party payor or other persons applicable to the provision of services must be reflected as a credit on any claim submitted to the Department for those services or items.

E-202.1 Charges 

Charges billed to the Department must be the provider’s usual and customary charge billed to the general public for the same service or item. Providers may only bill the Department after the service has been provided. 

Covered services must be billed to the Department using the Current Procedural Technology (CPT) codes or alphanumeric HCPCS codes. An audiologist may only charge for services he or she personally provides. A certified hearing instrument dispenser may only charge for the equipment dispensed. Providers may not charge for services provided by another provider, even though one may be in the employ of the other. 

Charges for services and items provided to participants enrolled in a Managed Care Entity (MCE) must be billed to the MCE according to the contractual agreement with the MCE. Information regarding MCE’s can be found on the HFS Care Coordination web page. 

E-202.2 Electronic Claims Submittal

Any services that do not require attachments or accompanying documentation may be billed electronically

Providers billing electronically should take special note of the requirement that Form HFS 194-M-C, Billing Certification Form, must be signed and retained by the provider for a period of three years from the date of the voucher. Failure to do so may result in revocation of the provider’s right to bill electronically, recovery of monies or other adverse actions. Form HFS 194-M-C can be found on the last page of each Remittance Advice that reports the disposition of any electronic claims.

Please note that the specifications for electronic claims billing are not the same as those for paper claims. Please follow the instructions for the medium being used. If a problem occurs with electronic billing, providers should contact the Department in the same manner as would be applicable to a paper claim. It may be necessary for providers to contact their software vendor if the Department determines that the service rejections are being caused by the submission of incorrect or invalid data. 

E-202.3 Claim Preparation and Submittal

The Department will not accept paper claim forms hand-delivered to HFS office buildings by providers or their billing entities. HFS will return hand-delivered claims to the provider identified on the claim form. All services for which charges are made must be coded on the appropriate claim form.

Form HFS 3797 (pdf), Medicare Crossover Form, is to be used to submit Medicare allowable crossover charges.

 Form HFS 1443 (pdf), Provider Invoice, is to be used to submit charges for audiological services provided to a Department’s Medical Programs participant.

 Form HFS 2210 (pdf), Medical Equipment /Supplies Invoice, is to be used to submit charges to the Department for a hearing aid, hearing aid accessories, supplies, equipment, hearing aid repairs and the dispensing fee.

The Department uses a claim imaging system for scanning paper claims. The imaging system allows efficient processing of paper claims and also allows attachments to be scanned. Refer to Appendix E-1 for technical guidelines to assist in preparing paper claims for processing. The Department offers a claim scanability/imaging evaluation. Turnaround on a claim scanability/imaging evaluation is approximately seven to ten working days and providers are notified of the evaluation results in writing

Provider Enrollment

Enrollment Requirements

An audiologist who is licensed by the Illinois Department of Professional Regulation or their state of practice is eligible to be considered for enrollment and participation in the Department’s Medical Programs. 

A certified hearing instrument dispenser who is not an audiologist but is registered by the Illinois Department of Public Health to dispense hearing aids is eligible to be considered for enrollment to participate in the Department’s Medical Programs. If enrollment is granted, the non-audiologist certified hearing instrument dispenser is enrolled as a medical equipment provider who may provide hearing aids, and hearing aid-related services such as accessories, supplies and repairs. 

An audiologist or certified hearing instrument dispenser who provides hearing aids and hearing aid related services such as accessories, supplies and repairs must also comply with requirements set forth in Chapter M-200, Handbook for Providers of Medical Equipment and Supplies. 

To comply with the Federal Regulations at 42 CFR Part 455 Subpart E - Provider Screening and Enrollment, Illinois has implemented a new electronic provider enrollment system. The web-based system is known as Illinois Medicaid Program Advanced Cloud Technology (IMPACT). 

Illinois IMPACT is a multi-agency effort to replace the Department’s Medicaid Management Information System (MMIS) with a web-based system that meets federal requirements. IMPACT is more convenient for providers and increases efficiency by automating and expediting state agency processes. 

Under the IMPACT system, category of service(s) (COS) is replaced with Specialties and Subspecialties. When enrolling in IMPACT, a Provider Type Specialty must be selected. A provider type subspecialty may or may not be required.

Enrollment Approval

When participation is approved, the provider will receive a computer-generated notification, the Provider Information Sheet, listing certain data on the Department’s computer files. The provider is to review this information for accuracy immediately upon receipt.

If all information is correct, the provider is to retain the Provider Information Sheet for subsequent use in completing claims (billing statements) to ensure that all identifying information required is an exact match to that in the Department files

Enrollment Denial 

When participation is denied, the provider will receive written notification of the reason for denial.

Within ten (10) calendar days after the date of this notice, the provider may request a hearing. The request must be in writing and must contain a brief statement of the basis upon which the Department's action is being challenged. If such a request is not received within ten (10) calendar days, or is received, but later withdrawn, the Department's decision shall be a final and binding administrative determination.

Provider File Maintenance 

The information carried in the Department’s files for participating providers must be maintained on a current basis. The provider and the Department share responsibility for keeping the file updated.

Provider Responsibility 

Information contained on the Provider Information Sheet is the same as in the Department’s files. Each time the provider receives a Provider Information Sheet, it is to be reviewed carefully for accuracy. The Provider Information Sheet contains information to be used by the provider in the preparation of claims; any inaccuracies found must be corrected and the Department notified immediately via IMPACT. 

Failure of a provider to properly update the IMPACT with corrections or changes may cause an interruption in participation and payments.

Department Responsibility 

When there is a change in a provider's enrollment status or the provider submits a change, the Department will generate an updated Provider Information Sheet reflecting the change and the effective date of the change. The updated sheet will be sent to the provider’s office address and to all payees listed if the payee address is different from the provider address.

E-203.2 Non-Audiologist Businesses

DME providers may provide hearing aids and hearing aid-related services and items but not professional audiology services for which an audiologist’s academic credentials and licensing are required. 

Certified hearing instrument dispensers are eligible to provide hearing aid fitting, sale of the hearing aid itself, hearing aid accessories, replacement parts and repairs.

E-203.3 Hearing Aids 

Providers must charge the actual acquisition cost of the hearing aid. The actual acquisition cost is the actual payment by the supplier for the hearing aid, taking into account any discounts, rebates or bonuses. The full amount of the discount must be subtracted when calculating the actual acquisition cost. The amount of any rebates or bonuses must be prorated to all purchases on which the rebate or bonus was earned. The prorated share must be subtracted when calculating the acquisition cost of the hearing aid. 

The date of service to be submitted when billing for a hearing aid is the date the hearing aid is dispensed, not the fabrication date. The participant must be eligible on the dispensing date for providers to receive reimbursement from the Department. 

A dispensing fee may be billed at the time the hearing aid is dispensed to the patient. The dispensing fee includes, but is not limited to payment for fitting, followup visits, shipping fees and retail mark-up for the hearing aid. 

Exception: HFS covers hearing aid batteries. Allowable quantities are listed on the fee schedule. Batteries are not covered for clients who reside in a Long Term Care (LTC) facility. It is the responsibility of the LTC facility to provide its residents with batteries as the cost of the hearing aid batteries are included in the payment made by the Department to the LTC facility. 

Provision of a hearing aid, whether by an audiologist or a DME provider, must include a minimum one-year warranty at no expense to the Department. Repair costs covered by the warranty are not to be submitted to the Department for payment. 

E-203.3.1 Hearing Aid Criteria

In order to be eligible for reimbursement from the Department for hearing aids, the following criteria must be met:

When testing is performed in an acoustically treated sound suite: 

The hearing loss must be 20 decibels (dB) or  greater at any two of the following frequencies: 500, 1000, 2000, 4000, 8000 Hertz (Hz), 

or 

The hearing loss must be 25 dB or greater at any one of 500, 1000, 2000 Hz.

When testing is performed at a site other than an acoustically treated sound suite:

The hearing loss must be 30 dB or greater at any two of the following frequencies: 500, 1000, 2000, 4000, 8000 Hz,

or 

The hearing loss must be 35 dB or greater at any one of 500, 1000, 2000 Hz 

E-203.4 Early Intervention Services

Early Intervention (EI) services are covered for children up to the age of three years, who are eligible for Part C services under the Individuals with Disabilities Education Act and when those services are included in the child’s Individualized Family Service Plan. Procedure codes for EI services must be billed to the EI Central Billing Office (CBO) for payment. In order to receive payment from the CBO, a provider must apply for and obtain an Early Intervention Credential, enroll as a provider with the CBO and have prior authorization to provide services.

• For credential and enrollment information, contact Provider Connections at 1-800-701-0995. 

• For questions about the service authorization and billing processes, contact the Early Intervention CBO Cornerstone Call Center at 1-800-634-8540.