Audiology Services

2

Overview

• Provider Enrollment Requirements • Member Eligibility • Hearing Services • Authorization and Billing • Additional Information

3

Provider Enrollment

4

Alaska Medicaid Provider Enrollment

• Providers must be enrolled in Alaska Medicaid to bill for reimbursement of covered health care services rendered to eligible Medicaid members

• Enrollment starts at the Enrollment portal. Go to http://medicaidalaska.com under Providers, then Enrollment

• Audiologist Licensing: – Active license under AS 08.11 to practice audiology individually or as a group – Out-of-state providers must also have active license as an audiologist and be enrolled in

the Medicaid program in state where services are provided • Hearing Aid Dealer Licensing

– Active license under AS 08.55 as a provider of hearing services and items – Out-of-state providers must also have active license as a provider of hearing services

and items and be enrolled in the Medicaid program in state where services are provided

5

Recordkeeping • Recordkeeping requirements are documented in the Individual Provider Agreement and Tax

Certification and Group Provider Agreement and Tax Certification • Although most recordkeeping requirements are consistent for all providers, some requirements

are provider-type specific • Providers must maintain complete and accurate clinical, financial, and other relevant records to

support the care and services for which they bill Alaska Medical Assistance for a minimum of 7 years from the date of service

• Providers are subject to audits, reviews and investigations

Providers must ensure their staff, billing agents, and any other entities responsible for any aspect of records maintenance meet the same requirements.

6

Member Eligibility

7

Member Eligibility Always verify member eligibility by using one of the following options: • Request to see the member's eligibility coupon or card that shows the current month of

eligibility; photocopy for your records • Call Automated Voice Response System (AVR):

– 855.329.8986 (toll-free) • Verify via Alaska Medicaid Health Enterprise website

– http://medicaidalaska.com • Fax complete Recipient Eligibility Inquiry Form - General

– 907.644.8126 • Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction • Call Provider Inquiry

– 907.644.6800, option 1 or 800.770.5650, option 1, 1 (toll-free)

8

Member Eligibility

9

Audiology Services

10

Audiologist Services

Audiologist covered hearing services and hearing items: • Identified in 7 AAC 115.530 • Rendered within scope of the audiologist’s license • Include audiometric evaluation, diagnostic testing, audiometric screening, rehabilitative

therapy, preventive services, corrective services, hearing items, and hearing item repairs • Cochlear implantation-related services

– Cochlear implantation-related services include: a preliminary assessment, programming of the device, adjustments, member education, auditory rehabilitation and treatment sessions

– Cochlear implantation replacement parts are covered if they are prescribed by an appropriate, enrolled provider

– Covered parts include a microphone, speech processor, and transmitter

11

Hearing Aid Dealer Services

Hearing Aid Dealer covered hearing services and hearing items: • Identified in 7 AAC 115.530 • Rendered within scope of the hearing aid dealer’s license • Includes hearing devices, accessories, supplies, repairs, and covered services when

prescribed by a licensed provider within the scope of their license • The department will not pay a hearing aid dealer

– For services rendered after the member waived the hearing evaluation – For a hearing test or diagnostic procedure designed to determine the cause of hearing

impairment

12

Covered Services and Items

• Providers must be enrolled and services or items covered • Hearing services and items must be identified by the prescriber as medically necessary to

alleviate a disability due to hearing impairment • Services or items must be least costly service that meets member’s medical need • Providers must include a manufacturer’s warranty of no less than one year from the

original purchase date for hearing items • Delivery and dispensing costs of new item or delivery of repaired item covered if item or

repair capabilities are unavailable in member’s municipality • Trial use if supported by medical documentation and proper service authorization obtained

to be covered

13

Non-covered Services and Items

• Administrative Expenses – Included in payment for covered services and items – Administrative expenses include telephone responses to questions, mileage, travel

expenses, travel time, equipment setup, installation, office inventory supply, and orientation and training regarding the proper use of equipment

• Assistive Listening Devices – Identified in HCPCS codes – Assistive listening devices include telephone amplifiers, alerters, television amplifiers,

television caption decoders, telecommunication devices for the deaf, and devices for use with a cochlear implant

• Charges submitted for adjustments, labor, repairs or replacement parts for a previously purchased hearing item when the department has purchased a newer like item

14

Labor, Repair or Replacement • When a damaged hearing item is no longer under warranty, labor will be paid to assess

and repair the item • Labor and repair will be covered if necessary for the hearing item to function as intended • Repairs will not be covered if replacement of item would be more cost effective • Claims must include:

– Statement describing the cause for and nature of repair – Description of item and its serial number if available – Documentation of labor charges

• Labor, repair or replacement will not be covered if: – Item is covered under manufacturer’s warranty – Item needs repair because of manufacturer’s defect – Item is a previously purchased hearing item and the department has since purchased a

newer like item for the member

15

Rental

• Rental or rent-to-purchase will not be covered if purchase is less expensive • Rental or rent-to-purchase will be paid as follows:

– Rental period thirty days or longer, monthly rental fee will be ten percent of allowed purchase price

– Rental period less than thirty days, amount paid = rental fee (as calculated above) / number of days in the month x number of days item was rented

• Rental periods over twelve months of continuous use will not be paid • Labor, repair and maintenance will not be paid before total rental fee payments equal the

allowed purchase price; these costs must be included in the rental fee • When total rental payments reach allowed purchase price, labor, repair or maintenance will

be paid after sixty days or when warranty expires, whichever is later

16

Hearing Aids - Covered

• No more than one hearing aid per ear, per member, per three calendar years • One fitting fee per ear, per purchase or rental of hearing aid • One dispensing fee per ear, per purchase or rental of hearing aid • Any type of monaural or binaural hearing aid that is worn in or behind the ear • If replacement is covered and manufacturer’s warranty is in effect, only difference between

deductible and maximum allowable will be paid

17

Hearing Aids

• Hearing aid supplies included with hearing aid: – Single cord – Y-cord – Harness – New receiver – Bone-conduction receiver with headband

18

Hearing Aids – Under Twenty One

• Unlimited ear mold impressions and ear molds • Unlimited hearing aid repairs if:

– Hearing aid warranty is no longer in effect and – Provider has not been paid a dispensing fee

• No more than two replacements of lost hearing aids if: – Hearing aid warranty is no longer in effect – Hearing aid was lost no more than three years after original purchase date – Written explanation of device loss is submitted with claim

• No more than two replacements of broken hearing aids if: – Hearing aid warranty is no longer in effect – Hearing aid was broken no more than three years after original purchase date – Hearing aid cannot be repaired, or cost of repairs exceeds replacement

19

Hearing Aids– Over Twenty One

• No more than two ear mold impressions and ear molds per ear, per three calendar years • No more than two hearing aid repairs if:

– Hearing aid warranty is no longer in effect and – Provider has not been paid a dispensing fee

• No more than one replacement of lost hearing aid if: – Hearing aid warranty is no longer in effect – Hearing aid was lost no more than three years after original purchase date – Written explanation of device loss is submitted with claim

• No more than one replacement of broken hearing aid if: – Hearing aid warranty is no longer in effect – Hearing aid was broken no more than three years after original purchase date – Hearing aid cannot be repaired, or cost of repairs exceeds replacement

20

Hearing Aids - Batteries

• Twenty hearing aid batteries a month up to one hundred and sixty a year per member • Thirty cochlear implant alkaline batteries per month • Fifty five cochlear implant zinc air batteries per month • If batteries are for hearing aid the department did not purchase, provider must record

manufacturer’s serial number and purchase date of the hearing aid

21

Authorization and Billing

22

Service Authorization

• Required for some services and items • Required for payment amounts that exceed the maximum allowable • Requests for replacement must show necessity of replacement and lack of warranty

coverage • Requested on a Certificate of Medical Necessity (CMN) form • Requests are reviewed on an individual basis • Factors considered include:

– Degree of member’s hearing loss – Type of hearing loss suffered – Configuration of member’s hearing loss – Management and treatment plan prepared

23

Fee Schedules Fee schedules tell you: • What services are covered • Maximum allowed reimbursement • Additional documentation

requirements • Other special considerations

Fee schedules can be found on http://medicaidalaska.com in the Documents & Forms section

24

Certificate of Medical Necessity

25

Certificate of Medical Necessity

26

Certificate of Medical Necessity

27

Service Authorization Tips

• For relevant services, be sure to use a modifier to indicate the ear to which a service will be rendered

• Make sure dates are within appropriate timeframes • Must attach an audiogram test report to CMN request or complete the clinical

assessment section with great detail, including the assessment or audiogram results

28

Billing

• 837P electronic transaction • Health Enterprise • Payerpath • CMS-1500, professional paper claim form

29

Additional Information

30

Overpayments & Repayment of Payment Errors

Providers should closely review each remittance advice (RA) to ensure it reflects accurate payment for all billed services, including correct member details and services provided. • In accordance with 7 AAC 105.220(e), Alaska Medical Assistance providers have 30 days

from the time of payment to notify the department in writing of a payment error. • Federal law (42 U.S.C. 1320(d)) requires repayment of overpayments to the department

within 60 days of identifying the overpayment. • Mail the written overpayment notification and a copy of the RA page detailing the

overpayment to the address below:

Conduent State Healthcare, LLC P.O. Box 240807 Anchorage, Alaska 99524-0807

31

Additional Resources

Alaska Medicaid Health Enterprise website at http://medicaidalaska.com. • Information necessary for successful billing • Includes provider-specific Medicaid billing manuals and fee schedules You may also call: • Provider Inquiry

– Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2 – Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),

option 1,1,1

© 2016 Conduent Business Services, LLC. All rights reserved. Conduent™ and Conduent Design™ are trademarks of Conduent Business Services, LLC in the United States and/or other countries.