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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 : 2.2.5 Hearing Aid Services : 2.2.5.1 Forms and Documentation

2.2.5.1
The forms and documentation required for the fitting and dispensing visits are as follows:
Physician’s Examination Report—The referring physician who performs the screening must complete the Physician’s Examination Report, which is maintained in the client’s medical record.
Hearing Evaluation, Fitting, and Dispensing Report (Form 3503)—The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must be completed by the fitter/dispenser that conducts the fitting and dispensing visit. The provider who signs the report must maintain it in the client’s file. The report includes audiometric assessment results of the hearing evaluation and must provide objective documentation to support improved communication ability with amplification. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply.
Client Acknowledgement Statement (created by the provider)—At the time the hearing aid device and supplies are dispensed, the client must sign a client acknowledgement statement to verify the client was evaluated and offered an appropriate hearing aid that meets the client’s hearing need. The acknowledgement statement must include language that indicates the client is responsible for paying any hearing aid rental fees if charged. The provider must obtain the signed acknowledgment statement before dispensing the hearing aid device and supplies and must keep the signed acknowledgment statement in the client’s file. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply.
30-Day Trial Period Certification Statement (created by the provider)—Fitters and Dispensers must inform clients in writing of the trial period lasting 30 consecutive days. The statement, which must be created by the provider and signed by the client, must contain the start and end dates of the trial period, all charges and fees associated with the trial period, an acknowledgment that the client accepts responsibility for any assessed rental fees, and the name, address, and telephone number of the State Board of Examiners for Speech-Language Pathology and Audiology. The client must receive a copy of this agreement.
After at least 30 days and the successful completion of the trial period, the provider must update the statement to indicate that the trial was successful and the client accepted the dispensed hearing aid device. The updated statement must be maintained in the client’s file. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply.
For hearing aids that are dispensed in a provider’s office, if a client fails to return by the end date of the trial period, the provider must contact the client. After 3 attempts have been made, if the client does not return to the provider’s office, the provider must document all attempts to contact the client and must maintain this documentation in the client’s file. Retrospective review may be performed to ensure documentation supports the contact attempts and the client’s failure to return to the provider’s office. This requirement does not apply for services that are rendered to clients who receive hearing aids in other places of service (i.e., nursing homes)

Texas Medicaid & Healthcare Partnership
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