Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER HIS-20 September 2003
TO:      Hearing Instrument Specialists Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner
RE:      Hearing Instrument Specialist Manual (Changes to Program Regulations and Service Codes)
Introduction
This letter transmits revisions to the Hearing Instrument Specialist Manual program regulations and service codes and descriptions. These revisions are effective for dates of service on or after October 1, 2003.
The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2003. New national service codes have been added, and MassHealth local codes have been removed from the Hearing Instrument Specialist Manual. The attached Subchapter 6 contains codes with modifiers, where applicable.
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for hearing aid dispensing services is 114.3 CMR 23.00: Hearing Aid Dispensers.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

Changes to the Hearing Instrument Specialist Regulations
The Hearing Aid Dispenser Manual has been renamed the Hearing Instrument Specialist Manual to reflect current licensure in Massachusetts.
I. Office Visits
Effective for dates of service beginning October 1, 2003, the Division will pay for office visits for evaluation and management services when certain procedures are required and provided as part of the office visit. These procedures include minor office repairs for which the provider customarily charges non-MassHealth patients, cleaning of the hearing aid, and the replacement of parts such as tubing and battery doors.

MASSHEALTH
TRANSMITTAL LETTER HIS-20 September 2003 Page 2
II. Refitting Services
Effective for dates of service beginning October 1, 2003, the Division will pay for additional professional fitting/refitting services for members for whom the hearing aid was dispensed more than two years prior to the date of the refitting services. These professional services must include a face-to-face encounter with the member. Payment will be made for a maximum of three visits per year.
Please see the attached revised Subchapter 4 of the Hearing Instrument Specialist Manual for complete information on covered services and any limits that may apply.
Updated Service Codes and Descriptions
Payment for Out-of-Office Services
For dates of service on or after October 1, 2003, providers will no longer be required to bill using MassHealth local modifier XX to receive enhanced payment for certain services provided in an out-of-office location. Providers must bill using the appropriate place-of-service code for the location where services were provided. The Division will automatically pay for out-of-office services in accordance with the applicable fee schedule of the Division of Health Care Finance and Policy.
Billing Guidelines
I.	Service Code Crosswalk
Attached is a crosswalk that shows the obsolete MassHealth service codes and the new national service codes for the revised Subchapter 6.
II.	Place-of-Service Codes
Providers must use the Division’s place-of-service (POS) code set when submitting on paper claim form no. 9 or on proprietary electronic media claim (EMC) format. Providers should refer to the billing instructions in Subchapter 5 of the Hearing Instrument Specialist Manual for a complete listing of all allowable Division POS codes. For 837 Professional claims, please coordinate the Division’s POS code list with the CMS POS list that is compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, and that is available at www.cms.hhs.gov/states/posdata.pdf.
III.	Billing Procedures for HIPAA Electronic Claims Requiring Attachments
Please refer to All Provider Bulletin 125, issued September 2003, for new procedures for
submitting HIPAA-compliant 837 professional claims that require attachments such as
manufacturer’s invoices.
Changes to Prior Authorization Process
I. Monaural Dispensing Fees
Effective for dates of service on or after October 1, 2003, providers must submit all requests for prior authorization (PA) for a monaural dispensing using the new national code, V5241 (dispensing fee, monaural hearing aid, any type). The Division will not accept Service Code V5090 for monaural dispensing for prior-authorization requests submitted on or after October 1, 2003.

MASSHEALTH
TRANSMITTAL LETTER HIS-20 September 2003 Page 3
Monaural dispensing services provided under any PA for V5090, that the Division has approved before October 1, 2003, may be billed under V5090 until the expiration date of the PA. All other claims for monaural dispensing, regardless of whether PA is required, must be submitted using V5241 for dates of service on or after October 1, 2003.
II.	Transition Period for Other Services
The Division is eliminating MassHealth-specific local service codes in compliance with HIPAA. For all prior-authorization requests that the Division has approved before October 1, 2003, that include approval for local service codes beginning with the letter “X,” providers may continue to bill for these services using the approved “X” codes for dates of service up to and including December 31, 2003. The Division will not accept any local “X” codes for dates of service beginning January 1, 2004.
The Division will transition any remaining approved PAs for local “X” codes where services have not yet been provided and the PA expires on or after January 1, 2004. Providers will be notified of any changes to their existing approved PAs. Providers will not be required to resubmit for a new PA.
III.	New Prior Authorization Request Process
Effective for dates of service on or after October 1, 2003, providers must submit all requests for prior authorization for hearing aids using the most specific HCPCS service code that is available. For example, if you are requesting PA for a monaural behind the ear (BTE) aid, the PA request should be submitted using the Service Code V5060 (hearing aid, monaural, behind the ear), instead of V5299 (hearing service, miscellaneous). If you are requesting PA for binaural, digitally programmable BTE aids, the PA request should be submitted using V5253, instead of V5299.
Service Code V5274 is available only for pocket-talkers.
Service Code V5298 is available for aids or devices that are not otherwise classified under the allowable HCPCS.
Service Code V5299 is available for other hearing-related services that are not otherwise classified under the allowable HCPCS.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Hearing Instrument Specialist Manual
Pages iv, vi, vii, 4-1 through 4-8, 6-1, and 6-2

MASSHEALTH
TRANSMITTAL LETTER HIS-20 September 2003 Page 4
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Hearing Instrument Specialist Manual
Pages iv, 4-5 through 4-8 — transmitted by Transmittal Letter HAD-19
Pages vi, vii, 4-3, and 4-4 — transmitted by Transmittal Letter HAD-16
Pages 4-1 and 4-2 — transmitted by Transmittal Letter HAD-18
Pages 6-1 and 6-2 — transmitted by Transmittal Letter HAD-17

Attachment
Transmittal Letter HIS-20
September 2003
Page 1
Hearing Instrument Specialist Service Code Crosswalk
Effective October 1, 2003

Obsolete Code - Description	New Code	New Code Description	Guideline	
V5090 - Dispensing fee;
unspecified hearing aid (monaural)	V5241	Dispensing fee, monaural hearing aid, any type		
X3400 - Batteries, not otherwise classified	V5266	Battery for use in hearing device	Bill per individual battery, regardless of package or battery size.	
X3402 - Batteries, 4 pack, sizes 13, 312, 675	

	
X3403 - Batteries, 4 pack, size 10, 230	

	
X3404 - Batteries, 6 pack, sizes 13, 312, 675	

	
X3405 - Batteries, 6 pack, size 230	

	
X3406 - Batteries, 8 pack, sizes 13, 312	

	
X3407 - Batteries, 8 pack, sizes 10, 230	

	
X3408 - Batteries, 8 pack, size 5	

	
X5200 - Hearing aid cleaning	99499	Unlisted evaluation and management service	Bill only one E/M service per member per date of service.	
X5294 - Accessories; costing $35.00 or less	V5267	Hearing aid supplies/accessories	Now only one service code for all accessories/options, regardless of unit cost.	
X5295 - Nubbin replacement	99499	Unlisted evaluation and management service	Bill only one E/M service per member per date of service.	
X5296 - Tubing replacement	99499	Unlisted evaluation and management service	Bill only one E/M service per member per date of service.	
X5298 - Earmold; costing $35.00 or less per unit	V5264	Ear mold/insert, not disposable, any type	Use appropriate HCPCS code, regardless of unit cost.	

	V5265	Ear mold/insert, disposable, any type	
	
X5299 - Earmold; costing more than $35.00 per unit	V5264	Ear mold/insert, not disposable, any type	Use appropriate HCPCS code, regardless of unit cost.	

	V5265	Ear mold/insert, disposable, any type	

Attachment
Transmittal Letter HIS-20
September 2003
Page 2

Obsolete Code - Description	New Code	New Code Description	Guideline	
X5300 - Accessories; costing more than $35.00	V5267	Hearing aid supplies/accessories	Now only one service code for all accessories/options, regardless of unit cost.	
X5301 - Ear impression	V5275	Ear impression, each		
Modifier XX - Out-of-office services	None	None. Use appropriate POS code for automatic payment.		
DMA place-of-service (POS) codes must be used on paper claim form no. 9 or proprietary EMC transactions.
1	Office, facility, or business location
2	Member’s home
3	Hospital inpatient
4	Hospital outpatient
5	Emergency room
6	Nursing home
07	Rest home
99	Other location
CMS POS codes must be used on HIPAA-compliant 837 Professional transactions. Please see www.cms.hhs.gov/states/posdata.pdf.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
iv	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
4.   PROGRAM REGULATIONS
416.401:      Introduction 		4-1
416.402:      Definitions 		4-1
416.403:      Eligible Members 		4-2
416.404:      Provider Eligibility 		4-2
416.405:      Out-of-State Services 		4-3
416.406:      Maximum Allowable Fees 		4-3
416.407:      Individual Consideration 		4-3
416.408:      Prior Authorization 		4-4
416.409:      Separate Procedures 		4-4
(130 CMR	416.410 through 416.413 Reserved)
416.414:      Dispensing Requirements 		4-5
416.415:      Conditions of Payment 		4-5
416.416:      Reimbursable Services 		4-6
416.417:      Nonreimbursable Services 		4-7
416.418:      Service Limitations 		4-7
416.419:      Recordkeeping Requirements 		4-7

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
6.   SERVICE CODES AND DESCRIPTIONS
Instrument Testing 		6-1
Office Visits for Evaluation and Management Services 		6-1
Refitting Services/Other Professional Services 		6-1
Hearing Aid Purchases-Monaural 		6-1
Hearing Aid Purchases-Binaural 		6-1
Hearing Aid Purchases-CROS and BICROS 		6-2
Hearing Aid Purchases-Other 		6-2
Hearing Aid Repairs, Accessories, and Related Services 		6-2
Hearing Aid Dispensing Fees 		6-2
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND
PERIODICITY SCHEDULE 		W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS CODES/MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
PREFACE	PAGE
vii	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
The regulations and instructions of the Division of Medical Assistance governing provider participation in MassHealth are published in the Provider Manual Series. The Division publishes a separate manual for each provider type.
Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. The Division's regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. Regulations promulgated by the Division of Medical Assistance are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title.
Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals.
Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For hearing instrument specialists, those matters are covered in 130 CMR Chapter 416.000, reproduced as Subchapter 4 in the Hearing Instrument Specialist Manual.
Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others.
The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead the Division's effort to give each provider a single convenient source for the essential information providers need in their routine interaction with the Division and with MassHealth members.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)	PAGE
4-1	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
416.401:  Introduction
130 CMR 416.000 governs services provided by hearing instrument specialists under MassHealth. A hearing instrument specialist who complies with 130 CMR 416.404, dispenses hearing aids or instruments, and provides services related to the care and maintenance of hearing aids or instruments is eligible to become a MassHealth provider. All hearing instrument specialists participating in MassHealth must comply with the regulations of the Division governing MassHealth, including but not limited to Division regulations set forth in 130 CMR 416.000 and 450.000.
416.402:  Definitions
The following terms used in 130 CMR 416.000 have the meanings given in 130 CMR 416.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 416.402 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 416.000 and in 130 CMR 450.000.
Accessories — those essential items or options on a hearing aid, including circuitry, purchased by a hearing instrument specialist that are not intrinsic components of the basic hearing-aid unit. Accessories do not include nonessential items such as carrying cases.
Adjusted Acquisition Cost — the unit price paid to a manufacturer by a hearing instrument specialist for a hearing aid or accessories, excluding postal-insurance charges. The adjusted acquisition cost does not exceed the manufacturer's current catalog price and is verified by a copy of the manufacturer's invoice retained by the hearing instrument specialist in the member's healthcare record as described under 130 CMR 416.419.
BICROS — a contralateral routing of signal (CROS) fitting with the addition of a second microphone for amplification in the better ear. Both microphones feed to a single receiver on the better ear, which is also hearing-impaired and requires amplification.
Binaural — the type of fitting or hearing aid necessitated by varying degrees of hearing loss in both ears that requires unparalleled amplification via the use of two microphones and two receivers.
Binaural Fitting — the fitting of two hearing aids, one to each ear, by a hearing instrument specialist; the fitting to the second ear taking place no later than six months after the fitting to the first ear.
CROS — contralateral routing of signal, which refers to the hearing-aid configuration that routes sounds from the unaidable hearing-impaired ear to the hearing ear through the use of a microphone on the hearing-impaired ear and a receiver on the hearing ear. The hearing ear could have normal hearing to mild hearing loss.
Date of Service — the date on which the medical service is furnished to a member or, in the case of hearing aids and accessories, the date on which the goods are delivered to a member.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)	PAGE
4-2	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
Dispense — the prescription of a hearing aid, its modification, its fitting, orientation to its use, and any adjustments required within the manufacturer's trial warranty period.
Dispensing Fee — a one-time-only fee for dispensing monaural or binaural hearing aids.
Electroacoustical Analysis — an objective measurement of a hearing aid’s specifications that may include, but is not limited to, acoustical gain, SSPL 90, frequency response, and harmonic distortion.
Major Repair — a repair to a hearing aid that must be made at a repair facility other than the hearing instrument specialist’s place of business.
Minor Repair — a repair to a hearing aid performed at the hearing instrument specialist’s place of business, such as, but not limited to, the replacement and cleaning of tubing.
Monaural Fitting — the fitting of one hearing aid by a hearing instrument specialist.
Out-of-Office Visit — treatment provided in a nursing facility or at the member’s residence rather than at the provider’s usual of business.
416.403:  Eligible Members
(A)	(1) MassHealth Members. The Division covers hearing-aid services only when provided to
eligible MassHealth members, subject to the restrictions and limitations described in the
Division’s regulations. The Division’s regulations at 130 CMR 450.105 specifically state, for
each MassHealth coverage type, which services are covered and which members are eligible
to receive those services.
(2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.
(B)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
416.404:  Provider Eligibility
Payment for services described in 130 CMR 416.000 will be made only to a hearing instrument specialist who is participating in MassHealth on the date of service.
(A)	In State. To participate in MassHealth, a hearing instrument specialist in Massachusetts must currently be licensed by the Commonwealth of Massachusetts, Division of Professional Licensure, Board of Registration of Hearing Instrument Specialists.
(B)	Out of State. To participate in MassHealth, a hearing instrument specialist located outside Massachusetts must:

(1)	be certified by the National Board for Certification in Hearing Instrument Sciences;
(2)	be licensed by the appropriate licensing agency in its own state (as applicable); and
(3)	participate in the medical assistance program in its own state.
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)	PAGE
4-3	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
416.405: Out-of-State Services
The Division pays out-of-state hearing instrument specialist in accordance with 130 CMR 450.109.
416.406: Maximum Allowable Fees
The Division pays the lowest of the following for hearing aids and related batteries and accessories:
(A)	the hearing instrument specialist’s usual and customary fee;
(B)	the adjusted acquisition cost; or
(C)	the maximum fee listed in the applicable fee schedule of the Massachusetts Division of Health Care Finance and Policy.
416.407:  Individual Consideration
Services designated "I.C." in the list of service codes and descriptions in Subchapter 6 of the Hearing Instrument Specialist Manual are given individual consideration by the Division to determine the amount of payment to be made to the hearing instrument specialist. The Division determines the amount of payment using the following criteria:
(A)	the time required to perform the procedure;
(B)	the degree of skill required to perform the procedure;
(C)	the severity or complexity of the member's hearing disorder or disability;
(D)	the policies, procedures, and practices of other third-party purchasers of health care; and
(E) the reasonable and customary practices of hearing instrument specialists.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMET SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)	PAGE
4-4	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
416.408:  Prior Authorization
(A)	Services designated "P.A." in the list of service codes and descriptions in Subchapter 6 of the
Hearing Instrument Specialist Manual require prior authorization from the Division. The Division
requires prior authorization for:
(1)	any hearing aid that costs more than the amount indicated in the applicable service description in Subchapter 6 of the Hearing Instrument Specialist Manual; and
(2)	the replacement of a hearing aid, regardless of the cost of the hearing aid, due to:

(a)	a medical change;
(b)	loss of the hearing aid; or
(c)	damage beyond repair to the hearing aid.
(B)	The Division requires the following documents from the provider requesting prior
authorization:
(1)	the audiological evaluation required under 130 CMR 416.414(A);
(2)	the previous audiological evaluation if the replacement hearing aid is needed because of a medical change;
(3)	a comprehensive report that justifies the medical necessity for the hearing aid;
(4)	a statement of the circumstances of the loss or destruction of the hearing aid (where applicable);
(5)	the medical clearance required under 130 CMR 416.414(B); and
(6)	an itemized estimate of the anticipated cost of the hearing aid.
(C)	All prior-authorization requests must be submitted in accordance with the billing instructions
in Subchapter 5 of the Hearing Instrument Specialist Manual. Prior authorization determines only
the health-care necessity of the authorized service and does not establish or waive any other
prerequisites for payment such as member eligibility or resort to health insurance payment.
416.409: Separate Procedures
Some procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it is designated as a "separate procedure" or "S.P." in the list of service codes and descriptions in Subchapter 6 of the Hearing Instrument Specialist Manual. Thus, when a procedure is performed alone for a specific purpose, it must be considered a separate procedure.
(130 CMR 416.410 through 416.413 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PAGE
4-5
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)
HEARING INSTRUMENT SPECIALIST MANUAL	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
416.414:  Dispensing Requirements
A hearing instrument specialist may dispense a hearing aid only after receiving the following documentation.
(A)	Audiological Evaluation.
(1)	The hearing instrument specialist must have received an audiological evaluation (air and
bone conduction, spondee thresholds, and word discrimination testing) performed by one of
the following:
(a)	an independent audiologist who is licensed and certified and who is a MassHealth provider;
(b)	a licensed, certified audiologist employed at a speech and hearing clinic that is a MassHealth provider; or
(c)	a licensed, certified audiologist employed by a physician or a hospital outpatient department that is a MassHealth provider.
(2)	This evaluation must contain the following information:
(a)	the date of the evaluation;
(b)	a favorable prognosis for adaptation to the hearing aid that ensures that: (i) any previous use of a hearing aid was successful; and (ii) no physiological causes exist that make the member unable to use a hearing aid;
(c)	the hearing aid make and model; and
(d)	whether or not the amplification should be monaural or binaural.
(3)	The evaluation must have been performed no more than six months before the dispensing date of the hearing aid.
(4)	The make, model, and specifications such as maximum output, frequency response configuration, and any other special requirements of the hearing aid dispensed must be the same as or comparable to that recommended in the audiological evaluation.
(B)	Medical Clearance. The hearing instrument specialist must have received a medical clearance
from a physician that states that the member has no medical conditions that would prohibit the use
of a hearing aid. The medical examination by the physician must have been performed no more
than six months before the dispensing date of the hearing aid.
416.415:  Conditions of Payment
(A)	To receive payment for dispensing a hearing aid, the hearing instrument specialist must submit with the completed claim form a copy of the entire manufacturer’s invoice, including all discounts. Manufacturers’ invoices must contain a date of service, the member’s name, and the serial numbers of the hearing aids that were dispensed to the MassHealth member. If the invoice is for a bulk order, the hearing instrument specialist must indicate on the copy of the invoice which hearing aids have been dispensed to the MassHealth member.
(B)	All claims must be submitted in accordance with the billing instructions in Subchapter 5 of the Hearing Instrument Specialist Manual.
(A)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)	PAGE
4-6	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
416.416: Reimbursable Services
(A)	Hearing-Aid Purchase. Payment for a hearing-aid purchase includes the following:
(1)	the hearing aid and standard accessories/options required for the proper operation of the hearing aid;
(2)	the proper fitting and instruction in the use, care, and maintenance of the hearing aid;
(3)	maintenance, minor repair, and servicing provided during the operational lifetime of the hearing aid that is furnished free of charge to non-MassHealth patients;
(4)	the initial one-year manufacturer's warranty against loss or damage; and
(5)	the loan of a hearing aid to the member by the hearing instrument specialist when necessary.
(B)	Earmold. An earmold is not reimbursable if it is included in the manufacturer's price of the
hearing aid or if the member already has an appropriate earmold. Payment for an earmold
includes the following:
(1)	the proper fitting of the earmold; and
(2)	any adjustments that may be needed during the operational life of the earmold.
(C)	Ear Impression.
(1)	For a Hearing Aid. Payment for an ear impression for a hearing aid includes one properly formed ear impression for each in-the-ear hearing aid purchased. The provider may not claim payment for an ear impression for a hearing aid until the hearing aid has actually been delivered to the member.
(2)	For an Earmold. The provider may not claim payment for an ear impression for an earmold until the earmold has actually been delivered to the member.
(D)	Batteries. Batteries must be new at the time of purchase.
(E)	Accessories. Payment for accessories and hearing-aid options includes proper fitting and
adjustment of the accessory as needed. Accessories must be billed separately from the basic
hearing-aid unit. The costs of the accessories, such as audio input cords and telephone coils, must
be combined into one single total charge and billed as one unit of service.
(F)	Major Repairs. The provider of a repair service is responsible for the quality of the
workmanship and parts, and for ensuring that the repaired hearing aid is in proper working
condition. The hearing instrument specialist is responsible for ensuring that the repaired hearing
aid is in proper working condition upon returning the aid to the member. Payment for a major
repair to a hearing aid is limited to the following conditions.
(1)	All warranties and insurance must have expired.
(2)	The hearing aid must be sent directly to the repair facility or manufacturer that will perform the repair. (The handling charges of an intermediary are not reimbursable.)
(3)	The repair service must include a written warranty against all defects for a minimum of six months.
(4)	A copy of the repair facility or manufacturer's invoice for the cost of the repair must accompany the claim form.
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
HEARING INSTRUMENT SPECIALIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 416.000)	PAGE
4-7	

	TRANSMITTAL LETTER
HIS-20	DATE
10/01/03	
(G) Office Visits for Evaluation and Management Services.
(1)	The Division pays for an office visit for evaluation and management services only when
one or more of the following services is required and is provided as part of the visit:
(a)	minor adjustments to the hearing aid to assure a proper fitting, such as an earmold adjustment, when the provider is not the provider who initially fit the hearing aid, and the provider who initially fit the hearing aid is no longer a MassHealth provider;
(b)	minor office repairs for which the provider customarily charges non-MassHealth patients;
(c)	cleaning of the hearing aid; or
(d)	replacement of parts such as, but not limited to, tubing, hooks, battery doors, and recasing.
(2)	The Division pays for only one office visit per member per date of service.
(H) Refitting Services/Other Professional Services. The Division pays for additional fitting/refitting services only where the hearing aid was dispensed more than two years prior to the date of service of the refitting services. These professional services include refitting of the aid, orientation, counseling with the member or member’s family, contact with interpreters, fitting of a loaner aid, and similar services. Payment for these services must include a face-to-face encounter with the member. Payment is made for a maximum of three visits per year.
416.417:  Nonreimbursable Services
The Division does not pay for any of the following services:
(A)	the rental of hearing aids;
(B)	hearing aids that are completely in the ear canal (CIC);
(C)	personal FM Systems; or
(D)	assistive technology devices provided under 34 CFR 300.308, where such devices are maintained at the school facility for the general use of disabled students, and assistive technology services provided under 34 CFR 300.308 relating to the use of such devices.
416.418: Service Limitations
The Division does not pay for more than one hearing aid per ear per member in a 60-month period without prior authorization in accordance with 130 CMR 416.408. One hearing aid per ear consists of either one binaural hearing-aid fitting, or two monaural hearing aids dispensed more than six months apart, with one aid dispensed for the left ear and the other dispensed for the right ear.
416.419:  Recordkeeping Requirements
A hearing instrument specialist must maintain a medical record for each member for a period of at least six years following the date of service. The record must contain all pertinent information about the services provided, including the date of service and the dates on which

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Division of Medical Assistance
Provider Manual Series
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materials were ordered and dispensed. The recordkeeping requirements are specific to each type of service and are described as follows.
(A)	Earmolds. The hearing instrument specialist must maintain the manufacturer's invoice indicating the actual acquisition cost for the earmold.
(B)	Hearing Aids. The hearing instrument specialist must maintain the following information in the member's medical record:
(1)	a history of the member's hearing loss and use of hearing aids. The history must contain
the following information:
(a)	the etiology and chronology of the member's hearing loss, including the member's age at the onset of the loss and an indication of whether the hearing loss is progressive;
(b)	the make, model number, type, and date of purchase of each hearing aid previously worn by the member;
(c)	a description of any speech and hearing therapy received by the member; and
(d)	a description of any handicap that the member has that may impair vision or affect hearing aid use;

(2)	all audiological evaluations. The evaluations must have been performed no more than six months before the dispensing dates of the hearing aid;
(3)	a medical clearance from a physician that states that the member has no medical conditions that would prohibit the use of a hearing aid. The medical examination must have been performed no more than six months before the dispensing date of the hearing aid; and
(4)	the manufacturer's invoice indicating the actual acquisition cost of the hearing aid, including all discounts, and the warranty indicating the terms of repair or replacement in the event of loss of or damage to the hearing aid.
(C)	Replacement Hearing Aids.
(1)	If the member's hearing aid has been lost, the hearing instrument specialist must maintain in the member's medical record a statement from the member or someone acting on the member's behalf (for example, an immediate family member or other legal representative), that describes the circumstances of the loss of the hearing aid.
(2)	If the member's hearing aid has been irreparably damaged, the hearing instrument specialist must maintain in the member's medical record a statement from the manufacturer documenting that the hearing aid cannot be repaired.
(D)	Batteries and Accessories/Options. The hearing instrument specialist must maintain in the
member's record the manufacturer's invoice indicating the actual acquisition cost of batteries or
accessories/options, or both, if the cost of any item is more than $35.00.
(E)	Audiological Evaluation. The results of all audiological evaluations must be fully
documented in the member’s record.
REGULATORY AUTHORITY
130 CMR 416.000:  M.G.L. c. 118E, §§ 7 and 12.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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601   Service Codes and Descriptions
Service
Code       Service Description
HEARING AID SERVICES
Instrument Testing
92592	Hearing aid check; monaural (provider was not the original dispenser and the instrument is
older than one year) (listening check of the instrument plus sound field testing of the instrument on the patient; may or may not be performed together with a diagnostic evaluation)
92593	binaural
92594	Electroacoustic evaluation for hearing aid; monaural (real ear measurement (REM) objective
test of hearing instrument performance in the patient's ear as compared to a target response and electroacoustical assessment of the performance evaluation of the hearing instrument as compared to its original factory specifications)
92595	binaural
Office Visits for Evaluation and Management Services
99499      Unlisted evaluation and management service
Refitting Services/Other Professional Services
V5011     Fitting/orientation/checking of hearing aid
Hearing Aid Purchases-Monaural
V5030     Hearing aid, monaural, body worn, air conduction (P.A. if cost exceeds $500) (I.C.)
V5040     Hearing aid, monaural, body worn, bone conduction (P.A. if cost exceeds $500) (I.C.)
V5050     Hearing aid, monaural, in the ear (P.A. if cost exceeds $500) (I.C.)
V5060     Hearing aid, monaural, behind the ear (P.A. if cost exceeds $500) (I.C.)
V5246     Hearing aid, digitally programmable analog, monaural, ITE (in the ear) (P.A. if cost exceeds $500)
(I.C.) V5247     Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) (P.A. if cost exceeds
$500) (I.C.) V5256     Hearing aid, digital, monaural, ITE (P.A. if cost exceeds $500) (I.C.) V5257     Hearing aid, digital, monaural, BTE (P.A. if cost exceeds $500) (I.C.)
Hearing Aid Purchases-Binaural
V5130	Binaural, in the ear (P.A. if cost exceeds $1,000) (I.C.)
V5140	Binaural, behind the ear (P.A. if cost exceeds $1,000) (I.C.)
V5150	Binaural, glasses (P.A. if cost exceeds $1,000) (I.C.)
V5252	Hearing aid, digitally programmable, binaural, ITE (P.A. if cost exceeds $1,000) (I.C.)
V5253	Hearing aid, digitally programmable, binaural, BTE (P.A. if cost exceeds $1,000) (I.C.)
V5260	Hearing aid, digital, binaural, ITE (P.A. if cost exceeds $1,000) (I.C.)
V5261	Hearing aid, digital, binaural, BTE (P.A. if cost exceeds $1,000) (I.C.)

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Division of Medical Assistance
Provider Manual Series
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601 Service Codes and Descriptions (cont.)
Service
Code       Service Description
Hearing Aid Purchases-CROS and BICROS
V5170	Hearing aid, CROS, in the ear (P.A. if cost exceeds $1,000) (I.C.)
V5180	Hearing aid, CROS, behind the ear (P.A. if cost exceeds $1,000) (I.C.)
V5190	Hearing aid, CROS, glasses (P.A. if cost exceeds $1,000) (I.C.)
V5210	Hearing aid, BICROS, in the ear (P.A. if cost exceeds $1,000) (I.C.)
V5220	Hearing aid, BICROS, behind the ear (P.A. if cost exceeds $1,000) (I.C.)
V5230	Hearing aid, BICROS, glasses (P.A. if cost exceeds $1,000) (I.C.)
Hearing Aid Purchases-Other
V5070	Glasses, air conduction (I.C.)
V5080	Glasses, bone conduction (I.C.)
V5100	Hearing aid, bilateral, body worn (I.C.)
V5274	Assistive listening device, not otherwise specified (I.C.) (Use this code only for pocket-talkers.)
V5298	Hearing aid, not otherwise classified (P.A.) (I.C.)
Hearing Aid Repairs, Accessories, and Related Services
V5014	Repair/modification of a hearing aid (I.C.)
V5264	Ear mold/insert, not disposable, any type (I.C.)
V5265	Ear mold/insert, disposable, any type (I.C.)
V5266	Battery for use in hearing device (per battery)
V5267	Hearing aid supplies/accessories (I.C.)
V5275	Ear impression, each
V5299	Hearing service, miscellaneous (P.A.) (I.C.)
Hearing Aid Dispensing Fees
V5160	Dispensing fee, binaural
V5200	Dispensing fee, CROS
V5240	Dispensing fee, BICROS
V5241	Dispensing fee, monaural hearing aid, any type