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Benefit and Policy Language Will Change for Hearing Devices, Effective November 1, 2018

Last updated on 9/21/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after November 1, 2018, benefit and policy language will change for hearing devices.

Benefit Changes

The age range will change for the following procedure codes:

Procedure Code

Type of Service

Updated Age Range

92595

Medical Service

0 to 20 years of age

92640

Medical Service

12 years of age or older

69711

Surgical

5 years of age or older

L8692

Other Medical, New DME

0 years of age or older

69711

Ambulatory Surgical Center

5 years of age or older

Replacement hearing aid batteries procedure code V5266 may be reimbursed if the following procedure codes have been paid within five years, any provider:

Procedure Codes

69714

69715

69717

69718

L8690

L8691

L8692

L8693

V5030

V5040

V5100

V5170

V5180

V5210

V5220

V5244

V5245

V5246

V5247

V5249

V5250

V5251

V5252

V5253

V5254

V5255

V5256

V5257

V5258

V5259

V5260

V5261

V5266

V5267

V5298

The following procedure codes will require prior authorization and will no longer be diagnosis restricted:

Procedure Codes

69930

S2235

The following procedure codes will require prior authorization:

Procedure Codes

S2235

L8499

L8615

L8616

L8617

L8618

69711

The following procedure codes will be limited to one equipment, supply, or service purchase every five years:

Procedure Codes

V5100

V5210

V5220

V5249

V5250

V5251

V5252

V5253

V5258

V5259

V5260

V5261

Hearing Devices Policy Language Updates

Hearing devices are a benefit for clients of any age. Some types of hearing devices are age restricted.

Hearing Aids and Related Services

Hearing aid devices and all hearing services are reimbursed in accordance with the Texas Administrative Code (TAC) 1TAC §355.8141.

Hearing aids do not require prior authorization for the initial hearing aid(s). Initial hearing aid(s) refers to the first hearing aid(s) obtained by a client per five year period.

Prior authorization is required for hearing aid repair in excess of one per rolling year. The prior authorization request must include documentation supporting the need for the requested repair.

Clients whose jobs are contingent on their possessing a hearing aid, and those clients who appear to have vocational potential and who need a hearing aid, may be referred to the Texas Workforce Commission (TWC) for hearing aids.

Hearing Aid Documentation Requirements

The Physician’s Examination Report must be completed by the referring physician and must be maintained in the client’s medical record. A new Physician’s Examination Report must be completed any time there is a change in the client’s hearing or a new hearing aid is needed.

Note: An advanced practice registered nurse (APRN) or a physician assistant (PA) under physician supervision and delegation may also complete the Physician’s Examination Report.

Prior to dispensing a hearing instrument, a provider must enter into a written contract with the client that meets the Texas Department of Licensing and Regulation (TDLR) rule requirements in 16 TAC §112.140. The signed contract should verify that:

  • The client has a 30-day trial period for the hearing aid.
  • If the client is not satisfied with the purchased hearing aid, the client may return it to the provider within the 30-day trial period. If the device is returned within the 30-day trial period, the provider may charge the client a rental fee not to exceed $2.00 per day. This fee is not a benefit of Texas Medicaid. The 30-day trial period and any charged rental fee must meet TDLR rule requirements in 16 TAC V112.140.

The contract must be executed prior to dispensing and must be maintained in the client’s medical record. The client must receive a copy of the executed contract.

All charges and fees associated with the trial period must be stated in the contract, which must also include the name, address, and telephone number of TDLR.

Hearing Aid Reimbursement – Additional Information

The date of service for ear molds is the date that the ear molds are dispensed to the client.

The limitation for procedure code V5264 for custom ear molds will be limited to three ear molds per rolling year, any provider.

Hearing evaluations must be recommended by a physician based on examination of the client.

Note: APRN or a PA under physician supervision and delegation may also perform the evaluation.

Home visit hearing evaluations and fittings are permitted only with documentation of the client’s need in the written order from the physician, APRN, or PA.

Each hearing aid may be reimbursed once every five rolling years. Exceptions may be considered on a case-by-case basis with prior authorization.

Hearing Aid Repair

The limitation for repair or modification of a hearing aid will be limited to one per rolling year. Additional repairs beyond one rolling year may be considered with documentation supporting the need for the requested repair and are restricted to policy limitations.

Hearing Aid Trial Period

A trial period of up to 30 days is authorized by Texas Occupations Code §402.401. The 30 day trial period, and any charged rental fee, must meet the TDLR rule requirements in 16 TAC §112.140.

Abnormal Hearing Screen Results

All abnormal hearing screens for clients must be referred to a Texas Medicaid-enrolled provider that offers auditory services. Clients who are 20 years old and younger with abnormal screening results must be referred to a Texas Medicaid-enrolled provider experienced with the pediatric population who offers auditory services.

Cochlear Implants

Prior authorization is required for the cochlear implant surgical procedure, device, and replacement parts.

Bone Anchored Hearing Device (BAHD)

An implanted bone anchored hearing device (BAHD) is a benefit for clients who are five years old or older.

Authorization is required for BAHD sound processors that are worn on a soft headband.

A BAHD sound processor that is specifically worn on a soft headband is a benefit for clients five years old or younger. The BAHD sound processor is not implanted. A BAHD sound process worn on a soft headband may be reimbursed using procedure code L8692.

If chosen by the client, a BAHD sound processor worn on a soft headband may be a benefit for clients who are five years old and older.

Auditory Rehabilitation

The limitation for auditory rehabilitation will change to one evaluation and 12 visits per 180 day period without authorization.

Procedure code 92627 is an add-on procedure and must be billed with the primary procedure code 92626 to be considered for reimbursement.

Procedure code 92627 may be reimbursed up to four times per day to the same provider.

Authorization Requirements

Providers should use the Special Medical Prior Authorization (SMPA) Request Form for all prior authorization requests.

Non-Covered Services

Personal frequency modulated (FM) services are not a benefit of Texas Medicaid.

For more information, call the TMHP Contact Center at 800-925-9126.