audiologyservicesandhearingaidservicesmanual

Complete Audiology Services and Hearing Aid Services Manual

Audiology and Hearing Aid Services Manual

To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.

Update Log

Publication History

This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated January 2011, December 2011, March 2012, October 2016, September 2017, November 2019, January 2020, October 2023, and November 2023.

Update Log

11/09/2023

In the Non-Covered Services section, added over-the-counter hearing aids to the list of items not covered by Montana Healthcare Programs.

10/02/2023

Update the Non-Covered Services section.
Revise prior authorization information.
Clarify billing of miscellaneous/not otherwise classified codes.

01/01/2020

Cost Sharing Removed from the How Payment is Calculated Chapter.
All Chapters - "Medicaid" replaced with "Montana Healthcare Programs".

09/01/2019

In the Covered Services chapter, removed rental of hearing aids references; updated list of non direct member care services; changed warranty period language; updated monaural and binaural hearing aid requirements; and added miscellaneous codes.
In Prior Authorization Chapter, added to the PA requirements list.
Corrected Medicaid to Montana Healthcare Programs throughout the manual as appropriate.

09/27/2017
Audiology Services and Hearing Aid Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

06/20/2016
Audiology and Hearing Aid Services, July 2016: In summary, date only was amended on the cover, and the How Payment is Calculated section was updated to reflect the current cost share amount.

12/31/2015
Audiology Services and Hearing Aid Services, January 2016: HELP Plan-Related Updates and Others

06/30/2015
Audiology Services and Hearing Aid Services, June 2015: Entire Manual

02/04/2013
Audiology Services and Hearing Aid Services, 2013: Covered Services

End of Update Log Chapter

Key Contacts and Websites

See the Contact Us link in the left menu on the Montana Healthcare Programs Provider Information website for a list of contacts and websites.

End of Key Contacts and Websites Chapter

Introduction

Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for providers of audiology services and hearing aid services. Other essential information for providers is contained in the separate General Information for Providers Manual. Each provider is responsible for reviewing both manuals.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office.

Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.

The following rules and regulations are specific to the Audiology Services and Hearing Aid Services programs. Additional Montana Healthcare Programs rule references are available in the General Information for Providers Manual.

Administrative Rules of Montana (ARM)
- ARM 37.86.701 – ARM 37.86.705 Audiology Services
- ARM 37.86.801 – ARM 37.86.805 Hearing Aid Services

End of Introduction Chapter

Covered Services

General Coverage Principles

This chapter provides covered services information that applies specifically to services and supplies provided by audiology service and hearing aid providers. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.

Services Provided by Audiologists
Audiologists must hold a current audiology license issued by the Montana Board of Speech Language Pathologists and Audiologists under Title 37, Montana Code Annotated, be enrolled as a Montana Healthcare Programs provider and be the provider of the service. If the provider is serving members outside Montana, they must maintain a current license in the equivalent category under the laws of the state in which the services are provided. Audiology services are hearing aid evaluations and basic audio assessments provided to members with hearing disorders within the scope of service permitted by state law.

Services for Children (ARM 37.86.2201–2235)
Members under age 21 will be evaluated under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Well-Child program, which covers all medically necessary services for children under age 21.

Supplier Documentation (ARM 37.86.702)
Audiology services must be referred by a physician or mid-level practitioner. The referral must indicate that an audiological evaluation would be medically appropriate to evaluate the member’s hearing loss. Verbal referrals must be followed up by a written order received by the provider within 30 days. Referrals and orders are valid for Montana Healthcare Programs purposes for no more than 90 days.

Written orders, diagnostic and evaluation reports, and appropriate records that demonstrate compliance with Montana Healthcare Programs requirements, must be current and available upon the request of the Department or its designated representatives at no charge.

The audiologist’s written report must document the medical necessity for the service and shall contain the following information:

The member’s name, date of birth, and Montana Healthcare Programs identification number.
Results of audiometric tests at 500, 1000, 2000 and 3000 hertz for the right and left ears, and word recognition or speech discrimination scores at levels which ensure PB Max.
A written summary regarding the results of the evaluation indicating, in the provider’s professional opinion, whether a hearing aid is required, the type of hearing aid (e.g., in-the-ear, behind-the-ear, body amplifier) and whether monaural or binaural aids are requested.
The audiologist’s name, address and license number in typed or preprinted form.
The audiologist must sign and date the form.

The audiologist gives a copy of the report to the member to take to the hearing aid dispenser (if the audiologist is not providing the hearing aid). The audiologist retains the original report in the member’s medical file. The hearing aid dispenser submits the audiologist’s report to the Montana Healthcare Programs for approval of the hearing aid before dispensing of the aid.

For additional documentation requirements, see the General Information for Providers Manual, Provider Requirements chapter.

Non-Covered Services (ARM 37.85.207 )
Some services not covered by Montana Healthcare Programs include the following:

Services considered experimental or investigational.
Services provided to Montana Healthcare Programs members who are absent from the state, with the following exceptions:
- Medical emergency.
- Required medical services are not available in Montana. Prior authorization may be required; see the Passport to Health Manual and the Prior Authorization chapter in this manual.
- If the Department has determined that the general practice for members in a particular area of Montana is to use providers in another state.
- When out-of-state medical services and all related expenses are less costly than in-state services.
- When Montana makes adoption assistance or foster care maintenance payments for a member who is a child residing in another state.
Montana Healthcare Programs does not cover services that are not direct member care such as the following:
- Missed or canceled appointments.
- Mileage and travel expenses for providers.
- Preparation of medical or insurance reports.
- Service charges or delinquent payment fees.
- Warranty fee/replacement fee and/or deductible for replacing a lost hearing aid within the warranty period.

Some items not covered by Montana Healthcare Programs include the following:

Over-the-counter hearing aids
Wax filters
Domes
Wax picks
Ear plugs

Verifying Coverage
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service.

Fee schedules are available on the Provider Information website. Choose the Resources by Provider Type link in the menu on the left, read and accept the end user agreement. Navigate to your provider type page and select the link. The fee schedules are included in a tab labeled Fee Schedules.

Coverage of Specific Services

The following are specific criteria for certain items/services Montana Healthcare Programs covers that are either in addition to Medicare requirements or are services Medicare does not cover.

Basic Audio Assessments and Hearing Aid Evaluations
Basic audio assessments (BAA) must include at a minimum, for each ear, under ear phones in a sound-attenuated room:

Speech discrimination (word recognition) test under pb max conditions.
Speech reception thresholds.
Pure tone air conduction thresholds (at the frequencies of .5, 1, 2, 3, and 4 kHz).
Either pure tone bone thresholds at the above frequencies or tympanometry including tympanogram with acoustic reflexes and static compliance.

Hearing aid evaluation (HAE) includes those procedures necessary to determine the acoustic specifications most appropriate for the individual’s hearing loss.

Reimbursement for BAA or HAE includes all related supplies and items used in the performance of the assessment or evaluation.

Hearing Aids
For a hearing aid to be covered, the member must be referred by a physician or mid-level practitioner for an audiological exam, and the physician or mid-level practitioner must have determined that a hearing evaluation would be medically appropriate to evaluate the member’s hearing loss.

Monaural Hearing Aids
A monaural hearing aid will be covered at the fee scheduled amount if the examination by a licensed audiologist results in a determination that a hearing aid or aids are needed, and either of the following criteria is met:

For members aged 21 and older, the audiological examination results show that there is an average pure tone hearing loss of at least 40 decibels for each of the frequencies of 500, 1000, 2000 and 3000 hertz in the better ear and word recognition or speech discrimination scores are obtained at a level to ensure pb max.
For members aged 20 and under, the audiological examination results show that there is an average pure tone hearing loss of at least 25 decibels for each of the frequencies of 500, 1000, 2000 and 3000 hertz in the better ear.

Montana Healthcare Programs payment covers the manufacturer’s invoice price (excluding warranty charges) of the hearing aid. The invoice must contain the hearing aid model and serial number. Montana Healthcare Programs also will pay a dispensing fee. (See the Hearing Aid Fitting section below.)

Binaural Hearing Aids
Binaural hearing aids will be covered at the fee scheduled amount for adults aged 21 and older. All of the following criteria must be met:

The two-frequency average at 1 HkHz and 2 kHz must be greater than 40 decibels in both ears;
The two-frequency average at 1 kHz and 2 kHz must be less than 90 decibels in both ears;
The two-frequency average at 1 kHz and 2 kHz must have an interaural difference of less than 15 decibels;
The interaural word recognition or speech discrimination score must have a difference of less than 20%;
Demonstrated successful use of a monaural hearing aid for at least six (6) months; and
Documented need to understand speech with a high level of comprehension based on an educational or vocational need.

Use the fee schedule for your provider type to verify coverage for specific services.

Hearing Aid Fitting
The provider may bill Montana Healthcare Programs for a dispensing fee as specified in the fee schedule, in addition to the invoice price for the purchase of the hearing aid or aids. Hearing aid fitting must include either sound field testing in an appropriate acoustic environment or real ear measurements to determine that the hearing aid adequately fits the member’s needs. It also must include at least one follow-up visit and warranty coverage for the hearing aid for a period of at least one year.

Hearing Aid Replacement
For members aged 21 or over, a hearing aid purchased by Montana Healthcare Programs will be replaced once within a five year period and only if:

The original hearing aid has been lost or irreparably broken after the warranty period;
The provider’s records document the loss or broken condition of the original hearing aid; and
The hearing loss criteria specified in this manual continue to be met; or
The original hearing aid no longer meets the needs of the individual and a new hearing aid is determined to be medical necessary by a licensed audiologist.

Hearing Aid Miscellaneous Codes
When a provider bills with a miscellaneous code, a description of the item is required, or payment will be denied.

HCPCS codes V5014, V5264, V5267, V5298 and V5299 are reimbursed at the fee scheduled amount unless an invoice is submitted with the claim. If an invoice is submitted with the claim, the code will be reimbursed at invoice price or 75% of Manufacturers Suggested Retail Price (MSRP).

End of Covered Services Chapter

Prior Authorization

Prior authorization is required for hearing aids. No prior authorization is required for hearing aid services and supplies or the handling fee for hearing aid repairs or batteries. Montana Healthcare Programs does not pay for services when prior authorization requirements are not met.

To request prior authorization for hearing aids:

Submit prior authorization requests to Mountain Pacific Quality Health (MPQH), the DPHHS utilization review contractor, through the Qualitrac Portal.
Include appropriate supporting documentation with the request.

Upon completion of the review, the member and requesting provider are notified. The provider receives an authorization number that must be included on the claim. If the requesting provider does not receive the authorization number within 10 business days of being notified of the review approval, the requesting provider may call MPQH at (800) 219-7035.

Documentation Requirements:

Completed Hearing Aid Prior Authorization Request through the Qualitrac Portal.
Montana Medicaid Hearing Aid Prior Authorization Request Form.
Montana Medicaid Hearing Aid Certificate of Medical Necessity.
Include appropriate supporting documentation with the request. See the Prior Authorization Criteria section below.
Supporting documentation, which must include, at a minimum:
A copy of the physician or mid-level practitioner’s referral.
- Medical Clearance
- An audiogram.
- A report from the licensed audiologist.
For EPSDT reviews, the EPSDT Prior Authorization & Certificate of Medical Necessity form is required.
The forms above are on the Forms page of the Provider Information website. The Forms page link is under the Site Index drop-down on the Home page.

End of Prior Authorization Chapter

Billing Procedures

Using the Montana Healthcare Programs Fee Schedule

When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the applicable CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Department fee schedules are updated each January and July. Fee schedules are available on the Provider Information website. Choose the Resources by Provider Type link in the menu on the left, read and accept the end user agreement. Navigate to your provider type page and select the link. The fee schedules are included in a tab labeled Fee Schedules.

Place of Service

Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges.

Date of Service

The date of service for hearing aids or repairs is the day the hearing aid or repair is ordered from the manufacturer.

Using Modifiers

Review the guidelines for using modifiers in the applicable CPT manual and/or HCPCS coding book.
Always read the complete description for each modifier; some modifiers are described in the CPT manual while others are in the HCPCS book.
The Montana Healthcare Programs claims processing system recognizes only three pricing modifiers and one informational modifier per claim line. Providers are asked to place any modifiers that affect pricing in the first two modifier fields.
The HCPCS codes for monaural hearing aids require the use of modifiers to identify whether the aid is for the left (LT) or right (RT) ear. Use of the modifiers is mandatory for payment of monaural hearing aids. Monaural hearing aids billed without the LT or RT modifier will be denied.

Billings Tips for Specific Services

Hearing Aids
The provider bills for hearing aids using two separate procedure codes: one for the hearing aid and one for the dispensing fee. Valid diagnosis codes are mandatory on hearing aid claims. Providers may contact the physician or mid-level practitioner for the appropriate diagnosis code in a particular case. Also, a copy of the invoice must be attached to the claim. No other attachments are required.

Handling Fee for Repairs
Submit claims for hearing aid repairs with one charge for each service or supply item provided, and one charge for a handling fee.

Batteries
The maximum number of hearing aid batteries is four cells per month per hearing aid. The eight cells per month limit cannot be exceeded unless prior authorization has been received from the Department or its review organization.

End of Billing Procedures Chapter

How Payment Is Calculated

Overview

Although providers do not need the information in this chapter in order to submit claims to Montana Healthcare Programs, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

The RBRVS Fee Schedule

Most services by provider types covered in this manual are reimbursed for using the Department’s Resource-Based Relative Value Scale (RBRVS). The fee schedule includes several thousand CPT codes and HCPCS codes. Within the CPT coding structure, anesthesia services (00100–01999) and clinical lab services (almost the entire 80000–89999 range) are not reimbursed for using the RBRVS fee schedule.

RBRVS was developed for the Medicare program, which first implemented it in 1992. Medicare does a major update annually, with smaller updates performed quarterly. Montana Healthcare Programs implemented its RBRVS-based fee schedule in 1997. It is based largely on the Medicare model, with a few differences that will be described below. By adapting the Medicare model to the needs of the Montana Healthcare Programs, the Department was able to take advantage of the research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the U.S. by Montana Healthcare Programs s, Blue Cross and Blue Shield Plans, workers’ compensation plans and commercial insurers.

Many Montana Healthcare Programs payment methods are based on Medicare, but there are differences. In these cases, the Montana Healthcare Programs method prevails.

Fee Calculation
Each fee is the product of a relative value times a conversion factor.

Basis of Relative Values
For almost all services, Montana Healthcare Programs uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality.

For fewer than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.

Composition of Relative Values
For each code, the relative value is the sum of a relative value for the work effort (including time, stress, and difficulty), the associated transitional practice expense, and the associated malpractice expense.

Site of Service Differential
The Medicare program has calculated two sets of relative values for each code: one reflects the practitioner’s practice cost of performing the service in an office and one reflects the practitioner’s practice cost of performing the service in a facility.

Montana Healthcare Programs typically pays a lower fee if the service is provided in a facility because Montana Healthcare Programs typically also pays the facility.

Conversion Factor
The Department sets the conversion factor for the state fiscal year (July through June) and it is listed on the fee schedule.

Policy Adjuster
To encourage access to maternity services and family planning services, the Department increases fees for these codes using a policy adjuster. The fee listed on the fee schedule includes the policy adjuster.

Payment for Audiology Services

Montana Healthcare Programs payment for audiology services will be the lower of the provider’s usual and customary charge for the service or 100% of the published RBRVS fee schedule.

Payment for Hearing Aid Services

Montana Healthcare Programs payment for covered hearing aid services and items will be the lower of the provider’s usual and customary charge for the service or item, 75% of the submitted price on the invoice, or the Department’s fee schedule.

How Cost Sharing Is Calculated on Montana Healthcare Programs Claims

The member’s cost sharing amount is shown on the remittance advice and deducted from the Montana Healthcare Programs allowed amount. (See the Remittance Advices and Adjustments chapter in the General Information for Providers Manual).

How Payment Is Calculated on TPL Claims

When a member has coverage from both Montana Healthcare Programs and another insurance company, the other insurance company is often referred to as third party liability (TPL). In these cases, the other insurance is the primary payer and Montana Healthcare Programs makes a payment as the secondary payer. For example, a Montana Healthcare Programs member who also has insurance through her job receives a monaural hearing aid to wear behind their right ear (V5060RT). The invoice amount is $375.00. The member’s other insurance is billed first and pays $200.00. The Montana Healthcare Programs allowed amount for this item is the invoice amount up to $400.00. The amount the other insurance paid ($200.00) is subtracted from the Montana Healthcare Programs allowed amount ($375), leaving a balance of $175.00.

How Payment Is Calculated on Medicare Crossover Claims

When a member has coverage from both Medicare and Montana Healthcare Programs, Medicare is the primary payer. Montana Healthcare Programs will pay the Medicare co-insurance and deductible amounts not to exceed the Montana Healthcare Programs fee for the service for these dually eligible members. See the How Payment Is Calculated chapter in the Physician-Related Services Manual for details on how payment is calculated on Medicare crossover claims.

Professional Differentials
For some services within the scope of RBRVS payment methods, mid-level practitioners are paid differently. Audiologists are paid at 100% of the fee schedule.

Charge Cap
For the services covered in this manual, Montana Healthcare Programs pays the lower of the established Montana Healthcare Programs fee or the provider’s charge.

Payment by MSRP
About 4% of services covered by the RBRVS fee schedule do not have fees set for them; these services are typically rare or vaguely specified in the coding guidelines. For these services, payment is set at 75% of the amount submitted, which is the MSRP or, when no MSRP is available, the provider’s acquisition cost.

End of How Payment Is Calculated Chapter

Appendix A: Forms

For the forms listed below and others, see the Forms page on the Provider Information website.

Individual Adjustment Request
Paperwork Attachment Cover Sheet
Montana Medicaid Hearing Aid Prior Authorization Request Form
Montana Medicaid Hearing Aid Certificate of Medical Necessity

End of Appendix A: Forms Chapter

Appendix B: Definitions and Acronyms

For definitions and acronyms, see the Definitions and Acronyms link in the left menu on the Provider Information website.

End of Appendix B: Definitions and Acronyms Chapter

Appendix C: Search Options

This edition has three search options;

1. Search the whole manual. Open the Complete Manual tab. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.

2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.

3. Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

End of Appendix C: Search Options

End of Audiology Services and Hearing Aid Services Manual

Update Log

Publication History

This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated January 2011, December 2011, March 2012, October 2016, September 2017, November 2019, January 2020, October 2023, and November 2023.

Update Log

11/09/2023

In the Non-Covered Services section, added over-the-counter hearing aids to the list of items not covered by Montana Healthcare Programs.

10/02/2023

Update the Non-Covered Services section.
Revise prior authorization information.
Clarify billing of miscellaneous/not otherwise classified codes.

01/01/2020

Cost Sharing Removed from the How Payment is Calculated Chapter.
All Chapters - "Medicaid" replaced with "Montana Healthcare Programs".

09/01/2019

In the Covered Services chapter, removed rental of hearing aids references; updated list of non direct member care services; changed warranty period language; updated monaural and binaural hearing aid requirements; and added miscellaneous codes.
In Prior Authorization Chapter, added to the PA requirements list.
Corrected Medicaid to Montana Healthcare Programs throughout the manual as appropriate.

09/27/2017
Audiology Services and Hearing Aid Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

06/20/2016
Audiology and Hearing Aid Services, July 2016: In summary, date only was amended on the cover, and the How Payment is Calculated section was updated to reflect the current cost share amount.

12/31/2015
Audiology Services and Hearing Aid Services, January 2016: HELP Plan-Related Updates and Others

06/30/2015
Audiology Services and Hearing Aid Services, June 2015: Entire Manual

02/04/2013
Audiology Services and Hearing Aid Services, 2013: Covered Services

End of Update Log Chapter

Table of Contents

Key Contacts and Websites

See the Contact Us link in the left menu on the Montana Healthcare Programs Provider Information website for a list of contacts and websites.

End of Key Contacts and Websites Chapter

Introduction

Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for providers of audiology services and hearing aid services. Other essential information for providers is contained in the separate General Information for Providers Manual. Each provider is responsible for reviewing both manuals.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office.

Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.

The following rules and regulations are specific to the Audiology Services and Hearing Aid Services programs. Additional Montana Healthcare Programs rule references are available in the General Information for Providers Manual.

Administrative Rules of Montana (ARM)
- ARM 37.86.701 – ARM 37.86.705 Audiology Services
- ARM 37.86.801 – ARM 37.86.805 Hearing Aid Services

End of Introduction Chapter

Covered Services

General Coverage Principles

This chapter provides covered services information that applies specifically to services and supplies provided by audiology service and hearing aid providers. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.

Services Provided by Audiologists
Audiologists must hold a current audiology license issued by the Montana Board of Speech Language Pathologists and Audiologists under Title 37, Montana Code Annotated, be enrolled as a Montana Healthcare Programs provider and be the provider of the service. If the provider is serving members outside Montana, they must maintain a current license in the equivalent category under the laws of the state in which the services are provided. Audiology services are hearing aid evaluations and basic audio assessments provided to members with hearing disorders within the scope of service permitted by state law.

Services for Children (ARM 37.86.2201–2235)
Members under age 21 will be evaluated under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Well-Child program, which covers all medically necessary services for children under age 21.

Supplier Documentation (ARM 37.86.702)
Audiology services must be referred by a physician or mid-level practitioner. The referral must indicate that an audiological evaluation would be medically appropriate to evaluate the member’s hearing loss. Verbal referrals must be followed up by a written order received by the provider within 30 days. Referrals and orders are valid for Montana Healthcare Programs purposes for no more than 90 days.

Written orders, diagnostic and evaluation reports, and appropriate records that demonstrate compliance with Montana Healthcare Programs requirements, must be current and available upon the request of the Department or its designated representatives at no charge.

The audiologist’s written report must document the medical necessity for the service and shall contain the following information:

The member’s name, date of birth, and Montana Healthcare Programs identification number.
Results of audiometric tests at 500, 1000, 2000 and 3000 hertz for the right and left ears, and word recognition or speech discrimination scores at levels which ensure PB Max.
A written summary regarding the results of the evaluation indicating, in the provider’s professional opinion, whether a hearing aid is required, the type of hearing aid (e.g., in-the-ear, behind-the-ear, body amplifier) and whether monaural or binaural aids are requested.
The audiologist’s name, address and license number in typed or preprinted form.
The audiologist must sign and date the form.

The audiologist gives a copy of the report to the member to take to the hearing aid dispenser (if the audiologist is not providing the hearing aid). The audiologist retains the original report in the member’s medical file. The hearing aid dispenser submits the audiologist’s report to the Montana Healthcare Programs for approval of the hearing aid before dispensing of the aid.

For additional documentation requirements, see the General Information for Providers Manual, Provider Requirements chapter.

Non-Covered Services (ARM 37.85.207 )
Some services not covered by Montana Healthcare Programs include the following:

Services considered experimental or investigational.
Services provided to Montana Healthcare Programs members who are absent from the state, with the following exceptions:
- Medical emergency.
- Required medical services are not available in Montana. Prior authorization may be required; see the Passport to Health Manual and the Prior Authorization chapter in this manual.
- If the Department has determined that the general practice for members in a particular area of Montana is to use providers in another state.
- When out-of-state medical services and all related expenses are less costly than in-state services.
- When Montana makes adoption assistance or foster care maintenance payments for a member who is a child residing in another state.
Montana Healthcare Programs does not cover services that are not direct member care such as the following:
- Missed or canceled appointments.
- Mileage and travel expenses for providers.
- Preparation of medical or insurance reports.
- Service charges or delinquent payment fees.
- Warranty fee/replacement fee and/or deductible for replacing a lost hearing aid within the warranty period.

Some items not covered by Montana Healthcare Programs include the following:

Over-the-counter hearing aids
Wax filters
Domes
Wax picks
Ear plugs

Verifying Coverage
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service.

Fee schedules are available on the Provider Information website. Choose the Resources by Provider Type link in the menu on the left, read and accept the end user agreement. Navigate to your provider type page and select the link. The fee schedules are included in a tab labeled Fee Schedules.

Coverage of Specific Services

The following are specific criteria for certain items/services Montana Healthcare Programs covers that are either in addition to Medicare requirements or are services Medicare does not cover.

Basic Audio Assessments and Hearing Aid Evaluations
Basic audio assessments (BAA) must include at a minimum, for each ear, under ear phones in a sound-attenuated room:

Speech discrimination (word recognition) test under pb max conditions.
Speech reception thresholds.
Pure tone air conduction thresholds (at the frequencies of .5, 1, 2, 3, and 4 kHz).
Either pure tone bone thresholds at the above frequencies or tympanometry including tympanogram with acoustic reflexes and static compliance.

Hearing aid evaluation (HAE) includes those procedures necessary to determine the acoustic specifications most appropriate for the individual’s hearing loss.

Reimbursement for BAA or HAE includes all related supplies and items used in the performance of the assessment or evaluation.

Hearing Aids
For a hearing aid to be covered, the member must be referred by a physician or mid-level practitioner for an audiological exam, and the physician or mid-level practitioner must have determined that a hearing evaluation would be medically appropriate to evaluate the member’s hearing loss.

Monaural Hearing Aids
A monaural hearing aid will be covered at the fee scheduled amount if the examination by a licensed audiologist results in a determination that a hearing aid or aids are needed, and either of the following criteria is met:

For members aged 21 and older, the audiological examination results show that there is an average pure tone hearing loss of at least 40 decibels for each of the frequencies of 500, 1000, 2000 and 3000 hertz in the better ear and word recognition or speech discrimination scores are obtained at a level to ensure pb max.
For members aged 20 and under, the audiological examination results show that there is an average pure tone hearing loss of at least 25 decibels for each of the frequencies of 500, 1000, 2000 and 3000 hertz in the better ear.

Montana Healthcare Programs payment covers the manufacturer’s invoice price (excluding warranty charges) of the hearing aid. The invoice must contain the hearing aid model and serial number. Montana Healthcare Programs also will pay a dispensing fee. (See the Hearing Aid Fitting section below.)

Binaural Hearing Aids
Binaural hearing aids will be covered at the fee scheduled amount for adults aged 21 and older. All of the following criteria must be met:

The two-frequency average at 1 HkHz and 2 kHz must be greater than 40 decibels in both ears;
The two-frequency average at 1 kHz and 2 kHz must be less than 90 decibels in both ears;
The two-frequency average at 1 kHz and 2 kHz must have an interaural difference of less than 15 decibels;
The interaural word recognition or speech discrimination score must have a difference of less than 20%;
Demonstrated successful use of a monaural hearing aid for at least six (6) months; and
Documented need to understand speech with a high level of comprehension based on an educational or vocational need.

Use the fee schedule for your provider type to verify coverage for specific services.

Hearing Aid Fitting
The provider may bill Montana Healthcare Programs for a dispensing fee as specified in the fee schedule, in addition to the invoice price for the purchase of the hearing aid or aids. Hearing aid fitting must include either sound field testing in an appropriate acoustic environment or real ear measurements to determine that the hearing aid adequately fits the member’s needs. It also must include at least one follow-up visit and warranty coverage for the hearing aid for a period of at least one year.

Hearing Aid Replacement
For members aged 21 or over, a hearing aid purchased by Montana Healthcare Programs will be replaced once within a five year period and only if:

The original hearing aid has been lost or irreparably broken after the warranty period;
The provider’s records document the loss or broken condition of the original hearing aid; and
The hearing loss criteria specified in this manual continue to be met; or
The original hearing aid no longer meets the needs of the individual and a new hearing aid is determined to be medical necessary by a licensed audiologist.

Hearing Aid Miscellaneous Codes
When a provider bills with a miscellaneous code, a description of the item is required, or payment will be denied.

HCPCS codes V5014, V5264, V5267, V5298 and V5299 are reimbursed at the fee scheduled amount unless an invoice is submitted with the claim. If an invoice is submitted with the claim, the code will be reimbursed at invoice price or 75% of Manufacturers Suggested Retail Price (MSRP).

End of Covered Services Chapter

Prior Authorization

Prior authorization is required for hearing aids. No prior authorization is required for hearing aid services and supplies or the handling fee for hearing aid repairs or batteries. Montana Healthcare Programs does not pay for services when prior authorization requirements are not met.

To request prior authorization for hearing aids:

Submit prior authorization requests to Mountain Pacific Quality Health (MPQH), the DPHHS utilization review contractor, through the Qualitrac Portal.
Include appropriate supporting documentation with the request.

Upon completion of the review, the member and requesting provider are notified. The provider receives an authorization number that must be included on the claim. If the requesting provider does not receive the authorization number within 10 business days of being notified of the review approval, the requesting provider may call MPQH at (800) 219-7035.

Documentation Requirements:

Completed Hearing Aid Prior Authorization Request through the Qualitrac Portal.
Montana Medicaid Hearing Aid Prior Authorization Request Form.
Montana Medicaid Hearing Aid Certificate of Medical Necessity.
Include appropriate supporting documentation with the request. See the Prior Authorization Criteria section below.
Supporting documentation, which must include, at a minimum:
A copy of the physician or mid-level practitioner’s referral.
- Medical Clearance
- An audiogram.
- A report from the licensed audiologist.
For EPSDT reviews, the EPSDT Prior Authorization & Certificate of Medical Necessity form is required.
The forms above are on the Forms page of the Provider Information website. The Forms page link is under the Site Index drop-down on the Home page.

End of Prior Authorization Chapter

Billing Procedures

Using the Montana Healthcare Programs Fee Schedule

When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the applicable CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Department fee schedules are updated each January and July. Fee schedules are available on the Provider Information website. Choose the Resources by Provider Type link in the menu on the left, read and accept the end user agreement. Navigate to your provider type page and select the link. The fee schedules are included in a tab labeled Fee Schedules.

Place of Service

Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges.

Date of Service

The date of service for hearing aids or repairs is the day the hearing aid or repair is ordered from the manufacturer.

Using Modifiers

Review the guidelines for using modifiers in the applicable CPT manual and/or HCPCS coding book.
Always read the complete description for each modifier; some modifiers are described in the CPT manual while others are in the HCPCS book.
The Montana Healthcare Programs claims processing system recognizes only three pricing modifiers and one informational modifier per claim line. Providers are asked to place any modifiers that affect pricing in the first two modifier fields.
The HCPCS codes for monaural hearing aids require the use of modifiers to identify whether the aid is for the left (LT) or right (RT) ear. Use of the modifiers is mandatory for payment of monaural hearing aids. Monaural hearing aids billed without the LT or RT modifier will be denied.