Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter HIS-24 March 2009 TO: Hearing Instrument Specialists Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Hearing Instrument Specialist Manual (Changes to Program Regulations and Service Codes and Descriptions) This letter transmits changes to the program regulations and service codes and descriptions of the Hearing Instrument Specialist Manual. These changes are effective for dates of service on or after March 15, 2009. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of 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 paper copy of the publication. The regulation title for audiological services is 114.3 CMR 39.00: Rehabilitation Clinic Services, Audiological Services, Restorative Services. The regulation title for hearing aid dispensing services is 114.3 CMR 23.00: Hearing Aid Dispensers. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room 116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 www.mass.gov/sec/spr www.mass.gov/dhcfp I. Changes to Program Regulations • Provider Eligibility (130 CMR 416.404): These revised regulations codify existing eligibility criteria for acute hospital outpatient departments, hospital-licensed health centers, and other satellite clinics. Such providers are eligible under 130 CMR 416.000 to provide services designated as hearing aid services in the revised Subchapter 6 in accordance with 130 CMR 416.404(A). • Services for EPSDT-eligible members (130 CMR 416.408 and 416.410): These revised regulations codify existing policy for EPSDT-eligible members. MassHealth requires prior authorization for any medically necessary service not listed in Subchapter 6 for an EPSDT-eligible member, and any exception to a limitation on a service otherwise covered for an EPSDT-eligible member as described in 130 CMR 416.000. • Dispensing Requirements (130 CMR 416.414) • Audiological Evaluation: Effective for dates of service on or after March 15, 2009, the audiological evaluation for a MassHealth member aged 18 or older may be performed by either a licensed audiologist or a licensed hearing instrument specialist. An audiological evaluation performed by a hearing instrument specialist must meet the requirements of the Rules and Regulations Governing Hearing Instrument Specialists of the Massachusetts Division of Professional Licensure at 265 CMR 2.00-10.00. In accordance with M.G.L. c. 93, §§ 71 and 72, audiological evaluations for members under age 18 must be performed by a licensed audiologist. All audiological evaluations must be signed by the licensed individual(s) who personally performed the evaluation, and must include the individual’s name and credentials printed clearly and legibly next to the signature. • Medical Clearance: Effective for dates of service on or after March 15, 2009, the medical clearance must meet the revised minimum conditions listed at 130 CMR 416.414(B). The medical clearance must include the date of the clearance; state that the member is a candidate for and has no medical conditions that would contraindicate the use of a hearing aid(s); identify which ear(s) are cleared for hearing aid use; and indicate whether or not the member, at the time of the medical examination, currently owned or used a hearing aid for the designated ear(s). The medical clearance must be obtained no more than six months prior to the dispensing date of a hearing aid and must be personally signed by the physician. The physician’s name and credentials must be clearly printed on the medical clearance. • Reimbursable Services (130 CMR 416.416): Clarifications have also been made about billing for earmolds and ear impressions. An ear impression for an earmold for a BTE hearing aid is not separately reimbursable. Payment for the earmold includes payment for the ear impression. II. Changes to Service Codes and Descriptions in Subchapter 6 Effective for dates of service on or after March 15, 2009, service codes have been added for hearing testing and for ITC hearing aids. Clarifications have been made regarding the use of Service Codes 92592 and 92593. III. Other Reminders Effective for dates of service on and after August 1, 2006, providers must use either modifier LT (left ear) or RT (right ear) when billing for the purchase of a new monaural hearing aid and monaural dispensing fee. (See MassHealth Transmittal Letter HIS-23.) Failure to use these modifiers may result in a denied claim. Do not use these modifiers for services other than monaural hearing aid purchases and monaural dispensing. Use of these modifiers on other services will result in a denied claim. When billing on the CMS-1500 paper claim form, enter both the service code and the modifier in the appropriate boxes in Item 24D. When billing the 837P transaction, enter the five-character service code in Loop 2400 – SV101-2 and the two-character modifier in Loop 2400 – SV101-3. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Hearing Instrument Specialist Manual Pages iv, vi, 4-1 through 4-12, and 6-1 through 6-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Hearing Instrument Specialist Manual Pages iv and vi — transmitted by Transmittal Letter HIS-20 Pages 4-1 through 4-8, 6-1 and 6-2 — transmitted by Transmittal Letter HIS-23 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 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 ....................................................................................................... 4-4 426.410: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ................. 4-4 (130 CMR 426.411 through 426.413 Reserved) 416.414: Dispensing Requirements .............................................................................................. 4-5 416.415: Conditions of Payment ................................................................................................... 4-6 416.416: Reimbursable Services ................................................................................................... 4-6 416.417: Nonreimbursable Services ............................................................................................. 4-7 416.418: Service Limitations ........................................................................................................ 4-8 416.419: Recordkeeping Requirements ........................................................................................ 4-8 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 6. Service Codes and Descriptions Introduction ................................................................................................................................ 6-1 Service Codes and Descriptions .................................................................................................. 6-1 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/PPHSD Screening Services Codes.................................................................. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-1 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 416.401: 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 MassHealth regulations, including but not limited to those 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 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 medical 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. Complete Audiological Evaluation — an evaluation that includes a routine audiological examination (air and bone conduction, spondee thresholds, and word discrimination testing) as recommended by a physician. 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 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 custom-made goods, the date on which the goods are delivered to a member. 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-2 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 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. Independent Hearing Instrument Specialist – a hearing instrument specialist who is licensed in accordance with 130 CMR 416.404 and who is engaged in the practice of hearing aid dispensing through a private practice or self-employment, or both. 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 or 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 place of business. 416.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency covers hearing-aid services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. MassHealth 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 (A) In State. The following requirements apply when the practice is located in Massachusetts. (1) Independent Hearing Instrument Specialist. An independent hearing instrument specialist engaged in private practice in Massachusetts is eligible to participate in MassHealth only if the individual is licensed by the Commonwealth of Massachusetts, Division of Professional Licensure, Board of Registration of Hearing Instrument Specialists. (2) Acute Hospital Outpatient Department, Hospital-Licensed Health Center, or Other Satellite Clinic. An acute hospital’s outpatient department, hospital-licensed health center, or other satellite clinic that participates in MassHealth pursuant to the Executive Office of Health and Human Services (EOHHS) Acute Hospital Request for Applications (RFA) and contract is eligible to provide services designated as hearing aid services in Subchapter 6 of the MassHealth Hearing Instrument Specialist Manual for providers under 130 CMR 416.000. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-3 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 (B) Out of State. To participate in MassHealth, an independent hearing instrument specialist practicing outside of 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. 416.405: Out-of-State Services The MassHealth agency pays out-of-state hearing instrument specialists in accordance with 130 CMR 450.109. 416.406: Maximum Allowable Fees The MassHealth agency pays the lower of the following for hearing aids and related services: (A) the hearing instrument specialist’s usual and customary fee; or (B) 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 MassHealth agency to determine the amount of payment to be made to the hearing instrument specialist. The MassHealth agency 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 MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-4 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 416.408: 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 MassHealth agency. The MassHealth agency 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 MassHealth agency 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 administrative and billing instructions in Subchapter 5 of the Hearing Instrument Specialist Manual. Prior authorization determines only the medical 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. 416.410: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary hearing instrument specialist services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 416.000, and with prior authorization. (130 CMR 416.411 through 416.413 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-5 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 416.414: Dispensing Requirements A hearing instrument specialist may dispense a hearing aid only after receiving the following documentation. (A) Complete Audiological Evaluation. (1) The hearing instrument specialist must have received a complete audiological evaluation (air and bone conduction, spondee thresholds, and word discrimination testing) performed by one of the following: (a) an independent audiologist who personally performed and completed the audiological evaluation; (b) a licensed audiologist who is employed at a speech and hearing clinic and who personally performed and completed the audiological evaluation; or (c) a licensed audiologist who is employed by a physician, or by an acute hospital’s outpatient department, hospital-licensed health center, or other satellite clinic. (2) Audiological evaluations for members under age 18 must be performed by a licensed audiologist pursuant to M.G.L. c. 93 §§ 71 and 72. For members aged 18 or older, the audiological evaluation may also be performed by a licensed hearing instrument specialist. Hearing testing performed by a hearing instrument specialist must meet the requirements of the Massachusetts Rules and Regulations Governing Hearing Instrument Specialists of the Division of Professional Licensure at 265 CMR 2.00 through 10.00. (3) This evaluation must contain the following information: (a) the date of the evaluation; (b) a written summary of findings and impressions, which must include a favorable prognosis for hearing aid use and an assurance that no physiological causes exist that would make the member unable to use a hearing aid; (c) the recommended hearing aid make and model; (d) whether or not the amplification should be monaural (and if so, for which ear) or binaural; and (e) the signature of the audiologist or hearing instrument specialist who performed the evaluation, including the individual’s name and credentials printed clearly and legibly next to the signature. (4) The evaluation must have been performed no more than six months before the dispensing date of the hearing aid. (5) 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 and must maintain in the member’s medical record pursuant to 130 CMR 416.419(B) a medical clearance from a physician that meets the following conditions: (1) the medical clearance must state that the member is a candidate for and has no medical conditions that would contraindicate the use of a hearing aid; and (2) the medical examination by the physician must have been performed no more than six months before the dispensing date of the hearing aid; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-6 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 (3) the medical clearance must be signed by the physician. If the medical clearance is not printed on the physician’s letterhead, the physician’s name and credentials must also be printed clearly and legibly on the medical clearance; (4) the medical clearance must include the date of the medical clearance, identify which ears are cleared, and indicate whether or not the member, at the time of the medical examination, currently owns or uses a hearing aid for the designated ear. 416.415: Conditions of Payment All claims must be submitted in accordance with the administrative and billing instructions in Subchapter 5 of the Hearing Instrument Specialist Manual. 416.416: Reimbursable Services (A) Audiological Evaluation and Testing Services. Payment for an audiological evaluation will be made only if the evaluation is recommended by a physician. (B) Hearing-Aid Purchase. Payment for a hearing-aid purchase includes the following: (1) the hearing aid and standard accessories and 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 members; (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. (C) Earmold. The provider may not claim payment for an earmold until the earmold has actually been delivered to the member. 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 ear impression; (2) the proper fitting of the earmold; and (3) any adjustments that may be needed during the operational life of the earmold. (D) Ear Impression. (1) Ear Impression for an ITE/ITC Hearing Aid. Payment for an ear impression for a hearing aid includes one properly formed ear impression for each in-the-ear (ITE) or in-the-canal (ITC) 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) Ear Impression for an Earmold for a BTE Hearing Aid. An ear impression for an earmold for a behind-the-ear (BTE) hearing aid is not separately reimbursable. Payment for the earmold includes payment for the ear impression. (E) Batteries. Batteries must be new at the time of purchase. (F) 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-7 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 (G) 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 invoice from the repair facility or manufacturer for the cost of the repair must be kept in the member’s medical record. (H) Office Visits for Evaluation and Management Services. The MassHealth agency 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: (1) minor adjustments to the hearing aid to ensure 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; (2) minor office repairs for which the provider customarily charges non-MassHealth members; (3) cleaning of the hearing aid; or (4) replacement of parts such as, but not limited to, tubing, hooks, battery doors, and recasing. (I) Refitting Services and Other Professional Services. The MassHealth agency pays for additional fitting or 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. 416.417: Nonreimbursable Services The MassHealth agency 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-8 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 416.418: Service Limitations (A) The MassHealth agency 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. (B) Two monaural fittings dispensed within a six-month period, with one aid dispensed for the left ear and the other for the right ear, are defined as a single binaural fitting. The MassHealth agency does not pay two monaural dispensing fees for this service. MassHealth pays only one binaural dispensing fee for this service. (C) The MassHealth agency pays for the hearing tests listed in Subchapter 6 of the Hearing Instrument Specialist Manual only when provided for the sole purpose of hearing aid fitting and dispensing to an eligible member aged 18 or older. The MassHealth agency does not pay for services for which the provider does not customarily charge non-MassHealth members. 416.419: Recordkeeping Requirements A hearing instrument specialist must maintain a medical record for each member for a period of at least as long as the minimum period required by 130 CMR 450.205(G). The MassHealth agency does not pay a provider for services if the provider does not have adequate documentation to substantiate the provision of services payable under MassHealth. The medical record must contain all pertinent information about the services provided, including the date of service and the dates on which materials were ordered and dispensed. In no instance does the completion of the appropriate MassHealth claim form, the maintenance of a copy of such a claim, or the simple notation of service codes constitute sufficient documentation for the purposes of 130 CMR 416.419. 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 in the member’s medical record, 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 date of the hearing aid; (3) the medical clearance from a physician obtained in accordance with 130 CMR 416.414(B); and Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-9 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 (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) Accessories and Options. The hearing instrument specialist must maintain in the member's medical record the manufacturer's invoice indicating the actual acquisition cost of all accessories and options. (E) Audiological Evaluation. The results of all audiological evaluations must be fully documented in the member’s medical record. (F) Office Visits for Evaluation and Management Services. The hearing instrument specialist must maintain in the member's medical record documentation substantiating the necessity of the office visit and detailing the services provided. (G) Refitting Services and Other Professional Services. The hearing instrument specialist must maintain in the member's medical record documentation substantiating the necessity of the office visit and detailing the services provided. REGULATORY AUTHORITY 130 CMR 416.000: M.G.L. c. 118E, §§ 7 and 12. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 416.000) Page 4-10 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 601 Introduction MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 416.000 and 450.000. A hearing instrument specialist may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Hearing Instrument Specialist Manual. 602 Service Codes and Descriptions Service Code Service Description HEARING TESTING SERVICES 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only (S.P. 92553); 92553 air and bone 92555 Speech audiometry threshold (S.P. 92556) 92556 with speech recognition 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) 92590 Hearing aid examination and selection; monaural 92591 binaural INSTRUMENT TESTING 92592 Hearing aid check; monaural (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) (only if the instrument is older than two years; or if the provider was not the original dispenser, regardless of the age of the instrument) 92593 binaural (only if the instrument is older than two years; or if the provider was not the original dispenser, regardless of the age of the instrument) 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 (up to a maximum of six services per member per date of service) HEARING AID SERVICES Refitting Services/Other Professional Services V5011 Fitting/orientation/checking of hearing aid Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 602 Service Codes and Descriptions (cont.) Service Code Service Description Hearing Aid Purchases-Monaural (Must use with modifier LT or RT.) Prior authorization (P.A.) is required where the adjusted acquisition cost (A.A.C.), not including shipping charges, exceeds $500.00. One of the modifiers LT (left side) or RT (right side) must be used with these service codes. V5030 Hearing aid, monaural, body worn, air conduction (I.C.) V5040 Hearing aid, monaural, body worn, bone conduction (I.C.) V5050 Hearing aid, monaural, in the ear (I.C.) V5060 Hearing aid, monaural, behind the ear (I.C.) V5243 Hearing aid, analog, monaural, ITC (in the canal) (I.C.) V5245 Hearing aid, digitally programmable analog, monaural, ITC (in the canal) (I.C.) V5246 Hearing aid, digitally programmable analog, monaural, ITE (in the ear) (I.C.) V5247 Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) (I.C.) V5255 Hearing aid, digital, monaural, ITC (I.C.) V5256 Hearing aid, digital, monaural, ITE (I.C.) V5257 Hearing aid, digital, monaural, BTE (I.C.) Hearing Aid Purchases-Binaural Prior authorization (P.A.) is required where the A.A.C., not including shipping charges, exceeds $1,000.00. V5130 Binaural, in the ear (I.C.) V5140 Binaural, behind the ear (I.C.) V5150 Binaural, glasses (I.C.) V5249 Hearing aid, analog, binaural, ITC (I.C.) V5251 Hearing aid, digitally programmable analog, binaural, ITC (I.C.) V5252 Hearing aid, digitally programmable, binaural, ITE (I.C.) V5253 Hearing aid, digitally programmable, binaural, BTE (I.C.) V5259 Hearing aid, digital, binaural, ITC (I.C.) V5260 Hearing aid, digital, binaural, ITE (I.C.) V5261 Hearing aid, digital, binaural, BTE (I.C.) Hearing Aid Purchases-CROS and BICROS Prior authorization (P.A.) is required where the A.A.C., not including shipping charges, exceeds $1,000.00. V5170 Hearing aid, CROS, in the ear (I.C.) V5180 Hearing aid, CROS, behind the ear (I.C.) V5190 Hearing aid, CROS, glasses (I.C.) V5210 Hearing aid, BICROS, in the ear (I.C.) V5220 Hearing aid, BICROS, behind the ear (I.C.) V5230 Hearing aid, BICROS, glasses (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 602 Service Codes and Descriptions (cont.) Service Code Service Description Hearing Aid Purchases-Other Except where otherwise indicated, prior authorization (P.A.) is required where the A.A.C., not including shipping charges, exceeds $1,000.00. 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.) (P.A. if A.A.C. exceeds $500.00, not including shipping charges) (Use this code only for pocket talkers or similar single-unit amplifiers.) V5298 Hearing aid, not otherwise classified (P.A. always required) (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.) Cochlear Implant Batteries L8621 Zinc air battery for use with cochlear implant device, replacement, each (I.C.) L8622 Alkaline battery for use with cochlear implant device, any size, replacement, each (I.C.) L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each (I.C.) L8624 Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each (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 (Must use with modifier LT or RT.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Hearing Instrument Specialist Manual Transmittal Letter HIS-24 Date 03/15/09 This page is reserved