Current through Register 1531, September 27, 2024
Services designated "P.A." in the list of service codes and
descriptions in Subchapter 6 of the Audiologist Manual require
prior authorization from the MassHealth agency.
(A) 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 Audiologist Manual;
(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;
(3) certain hearing
aid related services as specified in Subchapter 6 of the Audiologist
Manual; and
(4) any
replacement of cochlear implant external components.
(B) The MassHealth agency requires the
following documents from the provider requesting prior authorization for
replacement of hearing aids, or certain hearing aid related services, as
applicable:
(1) the audiological evaluation
required under
130 CMR
426.414(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
426.414(B); and
(6) an itemized estimate of the anticipated
cost of the hearing aid.
(C) The MassHealth agency requires the
following documents from the provider requesting prior authorization for the
replacement of a cochlear implant processor:
(1) a comprehensive report that justifies the
medical necessity. The report must be within six months prior to the date of
service and must include the following:
(a) a
description and status of the member's current equipment;
(b) documentation of the current processor's
obsolescence;
(c) member's current
sound field results and speech testing results utilizing the member's current
cochlear implant processor; and
(d)
invoice stating cost of equipment requested.
(2) In the case of loss of a processor, a
description of the circumstances regarding the loss, an invoice stating cost of
equipment requested, and a list of the member's current equipment.
(D) All prior-authorization
requests must be submitted in accordance with the administrative and billing
instructions in Subchapter 5 of the Audiologist 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.
