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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook

Vision and Hearing
Services Handbook
Table of Contents
1 General Information 5
1.1 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 5
2 Nonimplantable Hearing Aid Devices and Related Services 6
2.1 Enrollment 6
2.1.1 School Districts, State Agencies, and Inpatient Facilities 6
2.2 Services, Benefits, Limitations, and Prior Authorization 6
2.2.1 Limitations and Required Forms 7
2.2.2 Hearing Screenings 7
2.2.2.1 Routine Hearing Screenings 7
2.2.2.2 Additional Hearing Screenings 8
2.2.2.3 Abnormal Hearing Screening Results 8
2.2.3 Audiology and Audiometry Evaluation and Diagnostic Services 8
2.2.3.1 Otological Examinations 9
2.2.3.2 Vestibular Evaluations 9
2.2.3.3 Forms and Documentation 9
2.2.3.4 Prior Authorization 9
2.2.3.5 * Limitations 10
2.2.3.6 SHARS Audiology Services 11
2.2.3.7 Noncovered Services 11
2.2.4 Hearing Aid Devices and Accessories (Nonimplantable) 12
2.2.4.1 Forms and Documentation 14
2.2.4.2 Prior Authorization 14
2.2.4.3 Limitations 15
2.2.5 Hearing Aid Services 16
2.2.5.1 Forms and Documentation 17
2.2.5.2 Prior Authorization 18
2.2.5.3 Limitations 18
2.3 Documentation Requirements 19
2.4 Claims Filing and Reimbursement 19
2.4.1 Claims Filing 19
2.4.1.1 Non-implantable Hearing Aid Devices 20
2.4.1.2 * Third Party Liability 20
2.4.2 Reimbursement 20
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines 20
3 Implantable Hearing Devices and Related Services 21
3.1 Enrollment 21
3.2 Services, Benefits, Limitations and Prior Authorization 21
3.2.1 Cochlear Implants 21
3.2.1.1 Prior Authorization 21
3.2.1.2 Limitations 22
3.2.1.3 Auditory Rehabilitation 23
3.2.2 Auditory Brainstem Implant (ABI) 23
3.2.2.1 Prior Authorization 24
3.2.2.2 Limitations 24
3.2.3 Bone-Anchored Hearing Aid (BAHA) 24
3.2.3.1 Prior Authorization 24
3.2.3.2 Limitations 25
3.2.4 Sound Processor Replacement and Repair 25
3.2.4.1 Prior Authorization 25
3.2.4.2 Limitations 25
3.2.5 Electromagnetic Bone Conduction Hearing Device - Removal Only 25
3.3 Documentation Requirements 26
3.4 Claims Filing and Reimbursement 26
3.4.1 Claims Filing 26
3.4.1.1 * Third Party Liability 26
3.4.2 Reimbursement 26
3.4.2.1 NCCI and MUE Guidelines 27
4 Vision Care Professionals 27
4.1 Enrollment 27
4.2 Provider Responsibilities 27
4.3 Services, Benefits, Limitations, and Prior Authorization 28
4.3.1 Services Performed in Long-Term Care Facilities 28
4.3.2 Services Performed in Federally Qualified Healthcare Centers (FQHC) 28
4.3.3 THSteps Medical Checkup Vision Screening 28
4.3.3.1 Vision Screening Outside of a THSteps Preventive Care Medical Checkup 29
4.3.4 Noncovered Services 29
4.3.5 Vision Testing 30
4.3.5.1 Routine Vision Testing 30
4.3.5.2 Medically Necessary Eye Examinations 31
4.3.5.3 Ophthalmological Examination and Evaluation with General Anesthesia 31
4.3.5.4 * Ophthalmic Ultrasound 31
4.3.5.5 Corneal Topography 33
4.3.5.6 * Gonioscopy 34
4.3.5.7 Sensorimotor Examination 34
4.3.5.8 * Orthoptic or Pleoptic Training 35
4.3.5.9 Special Ophthalmological Services 35
4.3.5.10 Ophthalmoscopy and Extended Ophthalmoscopy 36
4.3.5.11 Other Specialized Vision Services 37
4.3.6 Nonprosthetic Eyeglasses or Contact Lenses 37
4.3.6.1 * Eyeglass Lenses and Frames 38
4.3.6.2 Contact Lenses 41
4.3.6.3 Dispensing Requirements 42
4.3.6.4 Repair 42
4.3.6.5 Nonprosthetic Replacement 42
4.3.6.6 Medicare Coverage for Nonprosthetic Eyewear 43
4.3.7 Vision Services for Prosthetic Eyewear 43
4.3.7.1 Eyeglasses or Contact Lenses Following Cataract Surgery 44
4.3.7.2 Repair 44
4.3.7.3 Prosthetic Replacement 44
4.3.7.4 Intraocular Lens (IOL) and Additional Eyewear 45
4.3.7.5 Artificial Eyes 45
4.3.7.6 Ultraviolet (U-V) Protection 45
4.3.8 Surgical Vision Services 45
4.3.9 Prior Authorization 46
4.4 Documentation Requirements 46
4.5 Claims Filing and Reimbursement 46
4.5.1 Claims Filing 46
4.5.2 Reimbursement 47
4.5.2.1 NCCI and MUE Guidelines 47
5 Claims Resources 47
6 Contact TMHP 48
7 Forms 48
8 Claim Form Examples 48

Texas Medicaid & Healthcare Partnership
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