Department of Health and Family Services

June 2007 ! No. 2007-52

To:

Audiologists

HearingInstrumentSpecialists

Speech andHearing Clinics

HMOs and OtherManaged CarePrograms

Changes to Contracted Hearing InstrumentsEffective for hearing instrumentsdispensed on and after July 1, 2007,new contract agreements have beensigned for volume purchase hearinginstruments. This Update alsorepublishes policy, claims submissioninformation, and prior authorizationrequirements for hearing instrumentspecialists and audiologists.

Wisconsin Medicaid has signed volumepurchase contracts again with hearinginstrument manufacturers effective for hearinginstruments dispensed on and after July 1, 2007.Wisconsin Medicaid was directed in the 2003biennial budget to implement a volume purchaseprogram for durable medical equipment.

Procedure Code ChangesWisconsin Medicaid has added HealthcareCommon Procedure Coding System procedurecodes V5254 (Hearing aid, digital, monaural,CIC) and V5258 (Hearing aid, digital, binaural,CIC) to the volume purchase contract.

ManufacturersProviders may purchase hearing instrumentsfrom the manufacturers who have entered acontract with Wisconsin Medicaid. Refer toAttachment 1 of this Wisconsin Medicaid andBadgerCare Update for manufacturers whohave signed a volume purchase contract withWisconsin Medicaid and have at least onemodel available through this contract.

Attachment 1 also includes the address,telephone number, fax number, and deliverytime for each manufacturer.

PurchasePurchase rates have been established by themanufacturer for each hearing instrumentmodel. When submitting prior authorization(PA) requests or claims to Wisconsin Medicaid,providers are required to indicate the contractedpurchase rate of the hearing instrument model.Refer to Attachment 2 for a list of procedurecodes, procedure code descriptions,manufacturers, hearing instrument models,purchase rates, and repair rates covered by thevolume purchase contract. Providers arereimbursed at the net cash outlay for purchasedhearing instruments; for contracted hearinginstruments, the net cash outlay for purchase isthe contracted purchase rate. Providers arereminded that PA is required for the purchaseof any hearing instrument.

ShippingThe manufacturer covers shipping expenseswhen a contracted hearing instrument model issent to the provider or returned to themanufacturer.

Hearing Instrument PackageThe initial monaural hearing instrumentpurchase includes an ear mold and cord. Theinitial binaural hearing instrument purchase

kiliajmThis Update has been revised since its original publication. Information under procedure code V5256 has been changed for GN ReSound and Unitron Hearing, Inc and V5257 has been changed for Unitron Hearing, Inc. The changes have been highlighted in red.

Wisconsin Medicaid and BadgerCare Service-Specific Information ! June 2007 ! No. 2007-522

includes two ear molds and two cords.Batteries are not included in the initial hearinginstrument package. Providers may bereimbursed for batteries under procedure codeV5266 (Battery for use in hearing device).

Custom Ear MoldA custom ear mold (V5264) for a behind-the-ear hearing instrument is not included in thehearing instrument package. A custom ear moldis separately reimbursable for the same date ofservice (DOS) as the hearing instrumentpurchase and should be submitted on the sameclaim. If V5264 is billed before the hearinginstrument is billed, the reimbursement will berecouped when the provider is reimbursed forthe hearing instrument. Prior authorization is notrequired for custom ear molds.

For recipients under 18 years of age, three earmolds and impressions per hearing instrumentper year are allowed without PA. Priorauthorization is required if more than three earmolds and impressions are needed per hearinginstrument per year.

For recipients 18 years of age and older, oneear mold and impression per hearing instrumentper year is allowed without PA. Priorauthorization is required for more than one earmold and impression per hearing instrument peryear.

Hearing Instrument ModificationProviders may receive reimbursement for onemodification made by the manufacturer whenthe hearing instrument is purchased (V5014[Repair/modification of a hearing aid]). Toreceive reimbursement for the modification,providers are required to submit the claim onthe same DOS that the hearing instrument wasdispensed. Providers are required to usemodifier LT, RT, or 50 (Bilateral) as

appropriate. If modifier 50 is used formodification on a binaural hearing instrument,providers should request and submit claims forthe quantity of 2. Refer to the November2003 Update (2003-156), titled New policiesand clarifications for hearing instruments andrelated services, for more information onhearing instrument modifications.

DispensingEven if a hearing instrument is replaced by themanufacturer at no cost to the provider,recipient, or Wisconsin Medicaid, WisconsinMedicaid covers the dispensing and fitting ofreplaced hearing instruments. However,Wisconsin Medicaid will not cover theadditional dispensing if it occurs within 12months of the original service guarantee. Thedispensing of a hearing instrument includes thefollowing services: A 12-month service guarantee and any

necessary service to maintain properfunction of the hearing instrument.

Initial office visit. Proper fitting of the hearing instrument. Up to five post-fittings as necessary for

adjustments and hearing instrumentorientation. (This includes performancechecks.)

Performance CheckAlthough the trial period is 90 days, providersmay submit a claim to Wisconsin Medicaidafter the 30-day performance check iscomplete. A performance check is required 30days after the dispensing date. After the 30-dayperformance check is complete, providers maysubmit a claim for all procedures included indispensing the hearing instrument. Providersmay submit a claim after 45 days if therecipient has not returned for a performancecheck.

Even if a hearinginstrument isreplaced by themanufacturer atno cost to theprovider, recipient,or WisconsinMedicaid,WisconsinMedicaid coversthe dispensing andfitting of replacedhearinginstruments.

Wisconsin Medicaid and BadgerCare Service-Specific Information ! June 2007 ! No. 2007-52 3

If, after a claim has been paid, the hearinginstrument is returned to the manufacturerwithin 90 days and no replacement is made, theprovider is required to return the overpaymentto Wisconsin Medicaid within 30 days of thereturn. Providers should refer to the All-Provider Handbook for more information aboutrefunding overpayments.

If a replacement is made, no refund is required.Because the original dispensing serviceguarantee is not expired, Wisconsin Medicaidwill not cover the additional dispensing. Inaddition, no further reimbursement will be madefor the replacement hearing instrument.

Trial PeriodContracted hearing instrument models include a90-day trial period. If a hearing instrument is notsatisfactory to the recipient, the provider mayreturn the hearing instrument to themanufacturer within 90 days of the dispensingdate. The manufacturer will replace the hearinginstrument at no cost to the provider, recipient,or Wisconsin Medicaid. In order to assure thatthe recipient has adequately tried the hearinginstrument, the provider may not return thehearing instrument sooner than 30 days unlessthere is apparent damage. Prior authorization isnot required for hearing instruments replaced bythe manufacturer during the trial period.

Loss and Damage WarrantyContracted hearing instrument models arecovered by the manufacturer under a 12-monthloss and damage warranty.

Within 12 months of purchase, manufacturersare required to replace lost or damaged hearinginstruments at no cost to the provider, recipient,or Wisconsin Medicaid. No more than one lossor damage claim may be filed with themanufacturer per hearing instrument during the

12-month period. Because the originaldispensing service guarantee is not expired,Wisconsin Medicaid will not cover the additionaldispensing. In addition, no furtherreimbursement will be made for thereplacement hearing instrument. Priorauthorization is not required for replacing ahearing instrument that is covered under theloss and damage warranty.

If a hearing instrument is lost or damagedbeyond repair more than once during the 12-month period, PA is required for thereplacement hearing instrument.

Equipment WarrantyContracted hearing instrument models arecovered by the manufacturer under a 24-monthequipment warranty. The 24-month equipmentwarranty includes parts and labor. It does notcover the ear mold, cord, or batteries. Repairsneeded within 24 months of purchase will bemade by the manufacturer at no cost to theprovider, recipient, or Wisconsin Medicaid. Priorauthorization is not required to repair a hearinginstrument that is covered under the equipmentwarranty. After the dispensing serviceguarantee expires, providers may use CurrentProcedural Terminology (CPT) procedurecode 92592 (Hearing aid check; monaural) or92593 (Hearing aid check; binaural) forprofessional services associated with a majorrepair. Refer to the July 2006 Update (2006-63), titled Procedure Code Changes forAudiology Services, for a complete list ofallowable audiology procedure codes.

If, within 24 months of purchase, persistentrepairs are required due to equipment failure,the manufacturer may choose to replace thehearing instrument at no cost to the provider,recipient, or Wisconsin Medicaid. No furtherreimbursement will be made for the

C ontracted hearinginstrument modelsare covered by themanufacturerunder a 24-monthequipmentwarranty.

Wisconsin Medicaid and BadgerCare Service-Specific Information ! June