016.06.05 Ark. Code R. 009
Dealers
Hearing aid dealers must meet the following criteria to participate in the Arkansas Medicaid Program.
View or print a provider application (form DMS-652), Medicaid contract (form DMS-653) and Request for Taxpayer Identification Number and Certification (Form W-9).
Audiologists are eligible for participation in the Arkansas Medicaid Program if they meet the following criteria:
Group providers of Audiology Services must meet the following criteria to be eligible for participation in the Arkansas Medicaid Program.
NOTE: An audiologist licensed outside the state of Arkansas who has a Hearing Aid Dealer License and an Audiology License must enroll under both programs. A provider application and Medicaid contract must be completed for each program, and two (2) separate Medicaid provider numbers will be assigned.
Audiologists have the option of enrolling in the Title XVIII Medicare Program as providers of audiology services. When a recipient is dually eligible for Medicare and Medicaid and is provided services that are covered by both Medicare and Medicaid, Medicaid will not reimburse for those services if Medicare has not been billed prior to Medicaid billing. The recipient cannot be billed for the charges. Claims filed by Medicare "non-participating" providers do not automatically cross over to Medicaid for payment of deductibles and coinsurance.
NOTE: Providers enrolled to participate in the Title XVIII Medicare Program must notify the Provider Enrollment Unit of their Medicare provider number. View or print Medicaid Provider Enrollment Unit contact information.
The Utilization Review Section of the Division of Medical Services is responsible for authorizing hearing aid services for eligible Medicaid recipients under age 21. Services are provided as a result of a referral from the recipient's primary care physician (PCP). If the recipient is exempt from the PCP process, then the attending physician must make the referral. Licensed audiologists may provide vestibular testing, aural rehabilitation and aural habilitation services.
Prior to providing hearing aid services to an eligible Medicaid recipient, a medical clearance must be obtained from a physician. This clearance must indicate if there are any medical or surgical indications contrary to fitting the recipient with a hearing aid. An audiological exam must be made by a certified audiologist or a physician. Arkansas Medicaid will not reimburse for a hearing test performed by a State-licensed hearing aid dispenser unless the hearing aid dispenser is also a licensed physician or licensed audiologist. The hearing evaluation must include the audiologist's or physician's recommendations regarding the brand name and model of the hearing aid to be dispensed and the name of the Medicaid dealer the patient has chosen to provide the hearing aid. The cost of the hearing aid should be provided if available. The medical clearance and hearing evaluation and a copy of the audiogram must be forwarded to the Division of Medical Services Utilization Review (UR) Section and must reach the UR Section within 6 months from the date the above evaluations were performed. View or print the Division of Medical Services Utilization Review Section contact information. After reviewing the medical clearance from the physician and the audiological evaluation from the audiologist or the physician, a letter of authorization is sent from the Utilization Review Section to the Medicaid provider dispensing the hearing aid.
Fitting and servicing the hearing aid is performed by a licensed dispenser. The dealer must submit his or her claim for payment to EDS with the charges and serial numbers of the aid dispensed. Please refer to Section 240.000 of this manual for billing instructions and procedure codes regarding hearing aids.
The recipient is entitled to three follow-up visits to the dealer who dispensed the aid for the purpose of learning proper operation and care of the aid. The Medicaid Program does not reimburse the provider an additional amount for these three visits.
Use the following procedure codes for audiological function tests.
CPT Codes | ||||
92506 | 92507 | 92508 | 92541 | 92542 |
92543 | 92544 | 92545 | 92551 | 92552 |
92553 | 92555 | 92556 | 92557 | 92559 |
92560 | 92561 | 92562 | 92563 | 92564 |
92565 | 92567 | 92568 | 92569 | 92571 |
92572 | 92573 | 92575 | 92576 | 92577 |
92579 | 92582 | 92583 | 92584 | 92585 |
92586 | 92587 | 92588 | 92589 | 92590 |
92591 | 92594 | 92595 | 92700 |
Use the following procedure codes for hearing aid equipment for recipients under age 21 in the EPSDT program. Hearing aids are limited to two appliances per six-month period.
HCPCS Codes | ||||
V5030 | V5040 | V5050 | V5060 | V5120 |
V5130 | V5140 | V5170 | V5180 | V5210 |
V5299 |
National Code | Required Modifier(s) |
V5008 | EP |
V5008 | EP, U1 |
V5014 | - |
V5267 | - |
Field Name and Number | Instructions for Completion |
1. Type of Coverage | This field is not required for Medicaid. |
1a. Insured's I.D. Number | Enter the patient's 10-digit Medicaid identification number. |
2. Patient's Name | Enter the patient's last name and first name. |
3. Patient's Birth Date | Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card. |
Sex | Check "M" for male or "F" for female. |
4. Insured's Name | Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial. |
5. Patient's Address | Optional entry. Enter the patient's full mailing address, including street number and name (post office box or RFD), city name, state name and ZIP code. |
6. Patient Relationship to Insured | Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim. |
7. Insured's Address | Required if insured's address is different from the patient's address. |
8. Patient Status | This field is not required for Medicaid. |
9. Other Insured's Name | If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial. |
a. Other Insured's Policy or Group Number | Enter the policy or group number of the other insured. |
b. Other Insured's Date of Birth | This field is not required for Medicaid. |
Sex | This field is not required for Medicaid. |
c. Employer's Name or School Name | Enter the employer's name or school name. |
d. Insurance Plan Name or Program Name | Enter the name of the insurance company. |
10. Is Patient's Condition Related to: | |
a. Employment | Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO." |
b. Auto Accident | Check the appropriate box if the patient's condition was auto accident related. If "YES," enter the place (two letter State postal abbreviation) where the accident took place. Check "NO" if not auto accident related. |
c. Other Accident | Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related. |
10d. Reserved for Local Use | This field is not required for Medicaid. |
Number a. Insured's Date of Birth Sex b. Employer's Name or School Name c. Insurance Plan Name or Program Name d. Is There Another Health Benefit Plan? | This field is not required for Medicaid. This field is not required for Medicaid. Enter the insured's employer's name or school name. Enter the name of the insurance company. Check the appropriate box indicating whether there is another health benefit plan. |
12. Patient's or Authorized Person's Signature | This field is not required for Medicaid. |
13. Insured's or Authorized Person's Signature | This field is not required for Medicaid. |
14. Date of Current: Illness Injury Pregnancy | Required only if medical care being billed is related to an accident. Enter the date of the accident. |
15. If Patient Has Had Same or Similar Illness, Give First Date | This field is not required for Medicaid. |
16. Dates Patient Unable to Work in Current Occupation | This field is not required for Medicaid. |
17. Name of Referring Physician or Other Source 17a. I.D. Number of Referring Physician | Primary Care Physician (PCP) referral is required for Hearing Services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. Enter the 9-digit Medicaid provider number of the referring physician. |
18. Hospitalization Dates Related to Current Services | For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format. |
19. Reserved for Local Use | Not applicable to Hearing Services. |
20. Outside Lab? | This field is not required for Medicaid |
21. Diagnosis or Nature of Illness or Injury | Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with HCFA diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service. |
22. Medicaid Resubmission Code Original Ref No. | Reserved for future use. Reserved for future use. |
23. Prior Authorization Number | Enter the prior authorization number, if applicable. |
24. A. Dates of Service | Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service. |
1. On a single claim detail (one charge on one line), bill only for services within a single calendar month. 2. Providers may bill, on the same claim detail, for two (2) or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the span. | |
B. Place of Service | Enter the appropriate place of service code. See Section 242.200 for codes. |
C. Type of Service | Enter the appropriate type of service code. See Section 242.200 for codes. |
D. Procedures, Services or Supplies | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.110. |
Modifier | Use applicable modifier. |
E. Diagnosis Code | Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM. |
F. $ Charges | Enter the charge for the service. This charge should be the provider's usual charge to private clients. If more than one unit of service is being billed, enter the charge for the total number of units billed. |
G. Days or Units | Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A. |
H. EPSDT/Family Plan | Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral. |
I. EMG | Emergency - This field is not required for Medicaid. |
J. COB | Coordination of Benefit - This field is not required for Medicaid. |
K. Reserved for Local Use | When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after "GRP#." When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter the number in Field 33 after "GRP#." |
25. Federal Tax I.D. Number | This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment. |
26. Patient's Account No. | This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted. |
27. Accept Assignment | This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid. |
28. Total Charge | Enter the total of Field 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.) |
29. Amount Paid | Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. Do not enter any amount previously paid by Medicaid. (See NOTE below Field 30.) |
30. Balance Due | Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. NOTE: For Fields 28, 29 and 30, up to 26 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due. |
31. Signature of Physician or Supplier, Including Degrees or Credentials | The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
32. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office) | If other than home or office, enter the name and address, specifying the street, city, state and ZIP code of the facility where services were performed. |
33. Physician's/Supplier's Billing Name, Address, ZIP Code & Phone # PIN # GRP # | Enter the billing provider's name and complete address. Telephone number is requested but not required. This field is not required for Medicaid. Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K. Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#." |
Requests for hearing aids, accessories and repairs must be completed on Form CMS-1500 (formerly HCFA-1500) prior to being submitted to the Utilization Review Section.
The following documentation must accompany each request for a hearing aid:
All hearing aid providers should use code V5014 (Hearing Aid Repair and Service) when billing for hearing aid repairs. Code V5014 will require authorization prior to payment. All prior authorization requests should be submitted to the Hearing Aid Consultant, Division of Medical Services. View or print the Division of Medical Services Hearing Aid Consultant contact information.
Please use code V5267 when billing for hearing aid accessories.
016.06.05 Ark. Code R. 009