Hearing Services

Hearing services are PrimeWest Health-covered services. Before providers are reimbursed for hearing aid assessments or dispensing, a physician, physician assistant, or nurse practitioner must rule out medical or surgical indications contrary to fitting the member with a hearing aid. After ruling out contraindications, the physician then refers the member for an audiologic evaluation to determine if a hearing aid is necessary. An audiologist or otolaryngologist must provide the audiologic testing and, if a hearing aid is indicated, prescribe a specific hearing aid offered under the hearing aid volume purchase contract. An individual who is enrolled as a hearing aid dispenser, but is not an audiologist or otolaryngologist, may not perform audiologic evaluations or prescribe hearing devices.

The hearing aid service provider must dispense the hearing aid according to the hearing aid exam, selection, and prescription of the otolaryngologist and audiologist. The member is to see an audiologist within the hearing aid trial period so that the audiologist may determine the effectiveness of the hearing aid.

In addition to reimbursement for dispensing hearing aids, hearing aid service providers may bill for the following:

1. Batteries
2. Ear impressions
3. Ear molds for hearing aids
4. Hearing aid checks (programming/reprogramming)
5. Hearing aid repairs
6. Parts and accessories
7. Chargers for rechargeable hearing aids
8. Re-casing, remakes, shell modifications
9. Replacing battery doors and microphone protectors
10. Cochlear implants

Hearing aid service providers are not separately reimbursed for audiologic evaluations, hearing aid exams and selection, hearing aid checks to determine the effectiveness of the hearing aid, or home visits.

Enrolled Hearing Aid Dispensers

1. An individual may enroll as a hearing aid service provider if he/she is certified by the Minnesota Department of Health (MDH) as a hearing instrument dispenser.
2. Out-of-state hearing aid service providers who do not sell hearing aids/instruments in Minnesota must comply with licensing or registration requirements of the other state, but are not required to be certified in Minnesota.

Covered Services

Hearing Aid Volume Purchase Contract

Hearing aids must be provided by a contracted hearing aid service provider. Hearing aid service providers are paid the contract price plus a dispensing fee. Terms of the hearing aid contract are outlined below. Hearing aids must:

1. Be new, current production models.
2. Be complete instruments, including all necessary equipment to make it fully functional, carrying case, and all items necessary for a proper fit.
3. Use standard commercial batteries and battery sizes.
4. Be accompanied by a performance graph and invoice at the contracted price.
5. Have a minimum 24-month manufacturer warranty covering parts and labor. The warranty is exclusive of the ear piece, cord, and batteries.
6. Have a one-year loss and damage warranty.

Hearing aids do not include ear molds and accessories not included in the cost of the hearing aid but that are necessary to the member’s use of the hearing aid. Ear molds and ear impressions are billable for behind-the-ear (BTE) aids.

No extra charge may be made for specially molded ear pieces or ear molds, casing color choice, or hypo-allergenic or soft canal casing.

PrimeWest Health covers conformity evaluations. These services may be provided after the hearing aid is dispensed. Use HCPCS code V5020, which is billable during the 90-day hearing aid trial period.

Accessories including chest harnesses, tone and ear hooks, carrying cases, T-coils, audio boots, neck loops, etc., are billable when not included in the price of the hearing aid (check the contract for hearing aid features included in the price).

Hearing aids that do not prove satisfactory to a user are to be returned to the manufacturer within 90 days from the date the hearing aid is provided to the member at no cost to PrimeWest Health or the hearing aid dealer. PrimeWest Health requires that:

1. The contract price for a hearing aid cannot be further reduced or altered.
2. Orders for PrimeWest Health hearing aids may not be used to obtain, or grant, additional commercial discounts.
3. Manufacturers will not process hearing aid orders unless all authorization requirements are met.
4. The manufacturer may not charge extra for packaging, postage, insurance, or handling while the aid is under warranty.

Hearing Aids Not on Volume Purchase Contract List (Non-Contract Aids)

Hearing aid service providers must provide hearing aids under the terms of the volume purchase contract. If the audiologist prescribes a non-contract hearing aid, the hearing aid service provider must obtain authorization by providing either:

1. Reasons the contract aids will not meet the member's needs; or
2. Reasons the non-contract aid will meet the member's needs (describe extenuating circumstances that eliminate the possible use of a contract aid).

For repairs of non-contract hearing aids, refer to Hearing Aid Repairs below.

Dispensing Fee

PrimeWest Health will reimburse the hearing aid service provider one dispensing fee every five calendar years for fitting and dispensing a monaural or set of binaural hearing aids for a member. Claims are not eligible for payment until after the hearing aid has been dispensed. The dispensing fee includes:

1. Adjusting the hearing aid to the wearer, including the necessary programming on digital and digitally programmable aids;
2. Provision of at least three hearing aid batteries of the type necessary to operate the hearing aid;
3. Informing the member of the trial period;
4. Instructing and counseling the member on use and care of the hearing aid;
5. A written copy of the manufacturer’s warranty;
6. Returning the hearing aid to the manufacturer for repair during the 24-month warranty period for parts and labor; and
7. Replacing the aid during the 12-month replacement warranty period.

When billing dispensing fees for contralateral routing of signal (CROS) amplification systems from the volume purchase contract, use HCPCS code V5110. CROS and bilateral microphones with contralateral routing of signal (BiCROS) amplification systems now include a hearing aid. Continue to use V5240 for BiCROS systems. When billing a dispensing fee for a frequency modulation (FM) system, use HCPCS code V5090.

Hearing Aid Trial Period

The trial period for new hearing aids is 90 days. Hearing aids obtained under the volume purchase contract that are not satisfactory to the user may be returned to the manufacturer within 90 days after the dispensing date, but no sooner than 30 days.

The trial period consists of consecutive days beginning the day the hearing aid is provided to the member and must extend at least 30 days, but no more than 90 days. The hearing aid service provider must inform the member of the beginning and ending dates of the trial period, and refer the member to the prescribing audiologist when the aid cannot be adjusted to the member’s satisfaction. If the audiologist prescribes a hearing aid to replace the unsatisfactory aid, the hearing aid service provider must order the prescribed replacement aid.

Hearing Aid Replacement

PrimeWest Health covers one hearing aid or set of binaural hearing aids within a period of five years for an eligible member. If hearing aids must be replaced more often due to change in hearing, or hearing aid loss, theft, or irreparable damage, the provider must request authorization for a new aid. PrimeWest Health considers the member’s physical or mental impairment in determining whether circumstances were beyond the member’s control if the aid is lost or broken and will only approve a replacement in those cases.

Always verify member eligibility and prior receipt of a hearing aid(s) before dispensing or requesting an authorization.

PrimeWest Health will not replace a lost or broken hearing aid when PrimeWest Health has replaced a hearing aid twice within the five-year period previous to the date of request. In such cases when PrimeWest Health does not provide a hearing aid, the hearing aid service provider may provide the eligible member with a contract hearing aid at the contract price. The hearing aid and dispensing fee shall be paid by the member.

Batteries

Hearing aid batteries may not, at one time, be dispensed in a quantity that exceeds a 90-day supply. Hearing aid batteries may not be dispensed unless the member is in need of the batteries and has requested them. Batteries may be dispensed on the same date as the hearing aid is dispensed. However, the dispensing service must include the provision of at least three batteries. Replace and bill rechargeable batteries as necessary. If a charger is broken or lost, one replacement charger may be provided per year using code V5267.

Ear Impressions

Ear impressions needed for the purpose of custom making an in-the-ear (ITE) hearing aid and ear molds for BTE hearing aids are reimbursed as a separate service from the dispensing fee.

Ear Molds

Replacement ear molds for BTE hearing aids are covered.

Hearing Aid Checks (Programming/Reprogramming)

Hearing aid checks, including setting and resetting volume, programming and reprogramming, and other adjustments of digital and digitally programmable hearing aids, are billable services only after the hearing aid trial period. Hearing aid checks are limited to four checks per year. Claims for hearing aid checks with DOS prior to 90 days following the day of service for dispensing new aids will deny.

Hearing Aid Repairs

PrimeWest Health does not cover repairs or the cost of returning the aid to the manufacturer if the aid is under warranty. All claims (including non-contract hearing aid claims) for hearing aid repairs must include the purchase date and hearing aid warranty expiration date. The hearing aid service provider who bills for the repair must verify if the hearing aid warranty has expired by obtaining and submitting the following with the hearing aid repair claims:

1. Purchase date from the manufacturer
2. Purchase warranty expiration date of the hearing aid from the manufacturer

All hearing aid repairs are required to be warranted for a minimum of six months, whether sent to the manufacturer or performed by the hearing aid service provider. Most manufacturers on the volume purchase contract are providing a one-year repair warranty. However, some provide repair warranties as long as 24 months. Providers are responsible for checking the manufacturers repair warranty information listed on the contract from which the hearing aid was obtained. Specific repair warranty information is in the hearing aid volume purchase contract.

If the aid is under warranty, PrimeWest Health will not reimburse providers or manufacturers for repairs or the cost of returning the aid to the manufacturer.

The hearing aid repair rate is determined by the hearing aid volume purchase contract under which the aid was purchased. The hearing aid volume purchase contracts require manufacturers to honor the contracted repair rate for a period of three years following the expiration of the contract.

For non-contract hearing aids, those that were purchased outside the volume purchase contract, parts and labor, including manufacturer fees, constitute one repair charge.

Hearing aid repairs do not include re-casing, remakes, or shell modifications. Do not bill a hearing aid repair when the device requires a re-casing, a remake, or shell modification.

All hearing aid repairs costing over $400 require authorization.

Parts and Accessories

Hearing aid accessories including chest harnesses, tone and ear hooks, carrying cases, T-coils, audio boots, neck loops, etc., are billable when not included in the price of the hearing aid (check the contract for hearing aid features included in the price).

Telecoils

Telecoils are covered if not standard with recommended hearing aid in the following circumstances:

1. One aid per person;
2. When the audiologist determines a member needs the telecoil to use the telephone; and
3. After the audiologist determines that the member’s telephone is compatible with the hearing aid’s telecoil by report or direct examination.

Re-Casing, Remakes, Shell Modifications

Re-casing, remakes, and shell modifications are billable services. Providers must include a description of the service provided. For example, when billing a shell modification, the provider must describe the following:

1. Materials used (e.g., description and amount of compound to fill hole in shell)
2. Service provided (e.g., filled hole in shell, built up shell to adjust fit, or ground down shell to adjust fit)
3. Amount of time

When billing a re-case or remake, the provider must provide the manufacturer’s invoice with the claim.

Replacing Battery Doors and Microphone Protectors

Battery door and microphone protector replacements are billable. Providers must provide a description of the service delivered on the claim.

Systems Other Than Personal Hearing Aids

Authorization is required for all systems other than personal hearing aids. When such systems as vibrotactile devices or personal communicators (e.g., pocket talkers) are requested, justification is needed, just as for non-contract aids. The audiologist must also address the following points:

1. Why the person cannot use personal hearing aids (e.g., person’s unique inabilities to use auditory information provided via hearing aids); and
2. Documentation of expectation of person’s ability to recognize and use vibrotactile information, specific to vibrotactile instruments (e.g., response to environmental vibratory information or low frequency bone conducted vibratory information).

Bone-Anchored Hearing Aids (BAHA)

Overview

A bone-anchored hearing aid (BAHA) is a type of hearing aid that attaches to the bone behind the ear. The device transmits sound vibrations directly to the inner ear through the skull and bypasses the middle ear. It is primarily suited for people who have conductive hearing losses, unilateral hearing loss, single-sided deafness, and people with mixed hearing losses who cannot wear in-the-ear or behind-the-ear hearing aids.

Nonsurgical devices are worn on a headband or attached directly to the skin with adhesive. Surgical devices include an internal component and an external speech processor. BAHAs are also referred to as auditory osseointegrated devices.
PrimeWest Health covers U.S. Food and Drug Administration-approved BAHA devices dispensed according to their approval guidelines.

Eligible Providers

• Hospitals
• Physicians
• Audiologists

The following provider types may bill for specific parts and batteries identified in the table found in Billing section below.

• Hearing aid dispensers
• Medical suppliers

Eligible Members

If medically appropriate, PrimeWest Health covers fully or partially implantable BAHAs for members with a unilateral or bilateral conductive or mixed conductive and sensorineural hearing loss.

Authorization

Device repairs over $400 require authorization. Replacement of a BAHA and its external components is considered medically necessary when the existing device cannot be repaired or when replacement is required because a change in the member's condition makes the present unit non-functional and improvement is expected with a replacement unit.

Billing

Use the following table for billing codes and provider types that may provide and bill for the services listed. Note that certain BAHA devices require authorization.

Cochlear Implants

A cochlear implant is a prosthetic device that may help provide hearing to those who have profound deafness and would receive little or no benefits from hearing aids.

Payment for cochlear implantation and programming

Payment for cochlear implantation and programming will be considered when the following criteria are met.

Authorization

All cochlear implant purchases and replacement devices (L8614, L8619, L8627, L8628, and L8629) require authorization.

Adults

The following criteria must be met:

1. There must be a diagnosis of total sensorineural deafness that cannot be mitigated by use of a hearing aid in members whose auditory cranial nerves are stimulable
2. The member must have the cognitive ability to use auditory clues and a willingness to undergo an extended programs of rehabilitation
3. The member must have post-lingual deafness
4. The member must have reached adulthood, defined as at least age 18
5. The member must be free of middle ear infection, have an accessible cochlear lumen that is structurally suited to implantation, and have freedom from lesions in the auditory nerve and acoustic areas of the central nervous system
6. The member must not have any contraindications to surgery

Children

The following criteria must be met

1. Children must be at least 12 months old
2. There must be a diagnosis of bilateral profound sensorineural deafness with little or no benefit from a hearing (or vibrotactile) aid in patients whose auditory nerves are stimulable
3. The member must be free of middle ear infection, have an accessible cochlear lumen that is structurally suited to implantation, and have freedom from lesions in the auditory nerve and acoustic area of the central nervous system
4. The member must not have any contraindication to the implant, including those described in the product’s FDA-approved package insert
5. The child must be teachable/trainable (i.e., able to participate in the extensive rehabilitation post-operation)

Required documentation

1. All diagnosis with the appropriate ICD code
2. Medical history pertaining to the cochlear implant
3. Reports
4. Audiology: including the final report from any pre-cochlear implant hearing training (children)
5. Speech: including test results of age-appropriate closed-set work identification tasks and other tests
6. Psychology: including a clear statement as to the individual’s cognitive ability to participate in the post-surgical rehabilitation program

PrimeWest Health follows Medicare guidelines for members enrolled in PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP). CMS policy indicates cochlear implants may not be performed by an SLP.

Non-Covered Services

1. Replacement batteries provided on a scheduled basis regardless of actual need.
2. Services specified as part of the contract price when billed separately for payment, including charges for repair of hearing aids under warranty.
3. Routine screening of individuals or groups for identification of hearing problems.
4. Separate reimbursement for postage, handling, taxes, mileage, or pickup and delivery.
5. Disposable hearing aids, non-electronic hearing aids, telephone amplifiers, vibrating bed alarms, phone handsets, visual telephone ringers, swim molds, ear plugs, dry aid kits, moisture guards, wax filters, wax guards, retention cords, and safety clips such as Otoclips and Critter Clips, battery chargers, etc.
6. Ear care and comfort creams, cleansers or cleaning solutions, wax removal kits/systems, and hearing aid pads.
7. Regularly scheduled maintenance, cleaning, and checking of hearing aids, unless there has been a request or referral for the service by the person who owns the hearing aid, the person’s family, guardian, or attending physician.
8. Loaner hearing aid charges.
9. Canal type hearing aids.
10. Non-contract hearing aids obtained without authorization.
11. Services included with the dispensing fee when billed separately.
12. Hearing aid services to a resident of an LTCF if the services did not result from a request by the resident, a referral by a registered nurse or licensed practical nurse who is employed by the LTCF, or a referral by the resident’s family, guardian, or attending physician.
13. Hearing aid services prescribed or ordered by a physician if the physician or entity commits a felony listed in Title 42 United States Code (USC) Section 1320a – 7b, subject to the “safe harbor” exceptions listed in Title 42 Code of Federal Regulations (CFR) Part 1001, Section 952.
14. Warranty upgrades.
15. Hearing mold color upgrades.

Hearing Services Documentation Requirements and Approval Criteria

The following documentation requirements for medical records apply regardless of whether or not the hearing aid requires authorization. This information must also be attached to authorization forms, if authorization is required.

1. Physician’s medical clearance stating no contraindication for hearing aid use. This may include general support for amplification, if needed, to determine medical necessity. Hearing services for a resident of an LTCF must result from a request by the member or a referral by facility nursing staff or the member’s family, guardian, or attending physician, and be part of the member’s plan of care or ordered in writing by the attending physician.
2. Authorization requests for replacement aid(s) due to loss or damage must include the following:
   1. Documentation from the member’s primary care provider of the member’s physical or mental impairment that demonstrates the loss or damage was beyond the member’s control
   2. A copy of the member’s care plan that outlines steps that will be taken to prevent future losses for members residing in a nursing home (both long- and short-term stay), assisted living facility, group residential housing, Intermediate Care Facility (ICF), or other group housing
   3. A statement from the member’s parents or other caregivers (including daycare providers) demonstrating steps that will be taken to safeguard the replacement hearing instrument when authorization is sought to replace a child’s hearing instrument(s); (e.g., use of safety clips, headband, or other retention devices; storing the instruments in a secure location when child is sleeping/napping, etc.)
3. Audiologic recommendations including:
   1. Written recommendation for hearing aid(s) including manufacturer specifications; and
   2. Follow-up plan for determining effectiveness of hearing aid use.
4. Documentation supporting audiologic recommendations:
   1. Audiogram – air and bone thresholds, speech thresholds, word recognition scores for each ear or reason why this data was not obtained and report of substitute data (e.g., sound field, informal tests) – internal consistency of data needed;
   2. History of previous appliance use and status of current aid(s), if applicable;
   3. When evidence of middle ear dysfunction exists (e.g., abnormal tympanometry or audiometric conductive loss), audiologist must give rationale for recommending hearing aid use prior to documentation of normal middle ear function (e.g., previous diagnosis of inoperable otosclerosis); and
   4. Audiologist’s documentation of need for amplification, this may include interpretation of audiometric data relative to member’s communication needs, formal hearing aid evaluation, real ear measurements, sound field, etc.
5. An adult’s pure-tone average (PTA) must be 25 dB HL and a child’s PTA must be 20 dB HL or greater in the fitted ear to qualify for a hearing aid under this program, or authorization is required. The PTA is the average air-conduction threshold for 1000 and 2000 Hz, and 3000 Hz measured with an earphone.

Eligible Providers

Before providers are reimbursed for hearing aid assessments or dispensing, a physician, physician assistant, or nurse practitioner must rule out medical or surgical indications contrary to fitting the member with a hearing aid. The medical clearance must be performed within six months prior to dispensing. After ruling out contraindications, the physician then refers the member for an audiologic evaluation to determine if a hearing aid is necessary. An audiologist or otolaryngologist must provide the audiologic testing and, if a hearing aid is indicated, prescribe a specific hearing aid offered under the hearing aid volume purchase contract. An individual who is enrolled as a hearing aid dispenser, but is not an audiologist or otolaryngologist, may not perform audiologic evaluations or prescribe hearing devices.

The hearing aid service provider must dispense the hearing aid according to the hearing aid exam, selection, and prescription of the otolaryngologist and audiologist. The member shall see an audiologist within the hearing aid trial period so that the audiologist may determine the effectiveness of the hearing aid.

Billing

Claims for hearing services can be submitted on either the 837I or the 837P format.

Hearing aid claims require the use of either the NU modifier for purchase or the RB modifier for repair. Hearing aid claims will reject if submitted with RA or RP modifiers, as they are not allowed on hearing aid claims.

1. Claims for hearing aid purchases must include the following:
   1. The prescribing audiologist’s NPI
   2. The hearing aid’s model number in Loop 2400, SV101-7 exactly as written in the hearing aid volume purchase contract, or the model number of the hearing aid as noted on an approved authorization
   3. Correct modifiers – NU, LT, RT
   4. ICD-10 diagnosis code(s)
   5. Monaural aid = 1 unit
   6. Binaural aids = 1 unit

Do not bill accessories included with the initial hearing aid purchase.

2. Dispensing fee claims:
   1. Bill the usual and customary charge.
   2. Claims may not be submitted before the hearing aid(s) is dispensed.
   3. Use the appropriate HCPCS code.
   4. Bill dispensing fee procedure code for the type of hearing aid dispensed: monaural or binaural. Always bill the binaural dispensing fee when binaural hearing aid(s) are dispensed, whether the binaural unit consists of matching hearing aids or not.
   5. Monaural = 1 unit
   6. Binaural = 1 unit
   7. Dispensing fees require authorization whenever the hearing aid requires authorization.
   8. The dispensing fee is a professional service. Do NOT bill the dispensing fee with modifier NU.
3. Replacement claim for unsatisfactory hearing aid(s)
   1. If the provider has billed for an unsatisfactory hearing aid, the provider must submit a replacement claim for both the replacement hearing aid and all but one-half of the dispensing fee. Both the replacement hearing aid and dispensing fee require authorization.
   2. If the provider has not billed for the unsatisfactory aid and dispensing fee and it is the first hearing aid claim in five years, the new aid may be provided immediately without requesting authorization.
4. Claims for hearing aid repairs must include the following
   1. Correct model number
   2. Correct modifiers (RB, LT, RT, and 22, when appropriate)
   3. When billing repairs for both hearing aids, bill two lines with the binaural hearing aid, one unit on each line, and include the RB modifier on both lines with the corresponding RT/LT modifier (one on each line)
   4. Hearing aid purchase warranty expiration date entered in the comment section of the claim form using mm/dd/yy format
   5. Hearing aid volume purchase contract number in the comment section of the claim form for all contract hearing aids
5. Repair invoice for repairs of non-contract hearing aids
   1. Use code V5014 for billing the following:
      1. Battery door replacement
      2. Re-casing and/or re-plating (hearing aid is sent to manufacturer). However, if re-casing/re-plating is done in conjunction with other repairs, use the appropriate hearing aid code, model number, and appropriate modifiers, and submit the repair invoice with the claim.
      3. Shell modification (service performed by dispenser/audiologist in office – minor repairs to shell). Send invoice with claim listing time and materials and describe service performed.
6. Miscellaneous hearing aid services
   1. When billing with code V5299, a description of the service is required. Use this code for ear wax removal and cleaning not associated with a hearing aid check, hearing aid maintenance (ear hook, receiver and tube changes, etc.), and for other services that do not have a more specific HCPCS code
7. Hearing aid service – code V5011
   1. This code should be used for hearing aid checks or reprogramming when performed by hearing aid dispenser. Code V5011 cannot be billed with 92592 or 92593. Claims with DOS more than 90 days after the dispensing date will deny.

Repairs do not constitute replacement of minor parts or cleaning of a hearing aid.

Use the appropriate HCPCS codes to bill these services.

Hearing aid batteries: Bill hearing aid batteries in quantities of one unit per battery. Use code V5266 for billing a battery for use in a hearing device (limit: 90-day supply).

Hearing aid dispensing services cannot be billed under a hospital, clinic, or agency provider number. The Minnesota Department of Human Services (DHS) only reimburses individuals enrolled as hearing aid service providers for hearing aid services.

If a recommended hearing aid requires authorization, parts and accessories will not require an authorization. Use CPT code V5267 when billing for hearing aid supplies and accessories (e.g., chest harness, telecoils).

Do not bill separately for earwax removal as it is not reimbursed individually. It is bundled with the services provided by the audiologist.

Hearing Aid Contract Vendors, Models, Prices, and Codes

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Updated_11/7/2024