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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 2 Nonimplantable Hearing Aid Devices and Related Services : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.4 Hearing Aid Devices and Accessories (Nonimplantable) : 2.2.4.2 Prior Authorization

2.2.4.2
Prior authorization is not required for medically necessary hearing aid devices and supplies that are provided within the limitations outlined in the table above.
Prior authorization is required for the following:
Replacement hearing aid devices that are required within the same 5-year period. A replacement hearing aid device may be considered for prior authorization when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and measures to be taken to prevent reoccurrence must be submitted with the prior authorization request. Replacements will not be authorized when the equipment has been abused or neglected by the client, the client’s family, or the caregiver.
Hearing aid accessories for clients who are birth through 20 years of age. Requests for prior authorization for children’s hearing aid accessories including, but not limited to, chin straps, clips, boots, and headbands will be considered when the requests are submitted with documentation that shows that the client is birth through 20 years of age and that the requested supply is medically necessary for the proper use or functioning of the hearing aid device.
Hearing aid devices that are not currently a benefit of Texas Medicaid but that are medically necessary for clients who are birth through 20 years of age (using procedure code V5298).
The prior authorization request must include:
Additional medically necessary repairs or modifications beyond 1 per year.
For additional repairs or modifications, requests for prior authorization must include documentation that supports the need for the requested repair.
For services that require prior authorization, prior authorization must be obtained before the services are rendered. The prior authorization number must be included on the claim form when the claim is submitted to TMHP.
Prior authorization requests must be submitted to the TMHP Special Medical Prior Authorization (SMPA) Department with documentation that supports medical necessity for the requested device, service, or supply. Authorization may be submitted on the TMHP website at www.tmhp.com or by fax to 1-512-514-4213.
Important:
For clients who are birth through 20 years of age, if the authorization request is denied because it does not meet benefit criteria, the TMHP SMPA Department will refer the request to the TMHP Comprehensive Care Program (CCP) Department for consideration under CCP. The provider is not required to complete additional forms or request referral to the TMHP CCP Department.
Providers may use the form of their choice to submit the required information to the TMHP SMPA Department. No specific request form is required.
Refer to:
Section 6: Claims Filing (Vol 1, General Information) for more information about the authorizations and claims filing processes.

Texas Medicaid & Healthcare Partnership
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