Current through Register Vol. 35, No. 18, September 24, 2024
Once enrolled, a provider receives instructions on how to
access documentation, billing, and claims processing. Reimbursement to a
provider for covered services is made at the lesser of the following:
(1) the provider's billed charge; or
(2) the MAD fee schedule for the specific service or
procedure.
A. The provider's billed
charge must be his or her usual and customary charge for services.
B. "Usual and customary charge" refers to the
amount which the individual provider charges the general public in the majority
of cases for a specific procedure or service.
C.
Vision appliances: A vision
service provider, except an IHS facility, must submit claims for reimbursement
on the CMS 1500 claim form or its successor.
D.
Hearing appliances: A hearing
aid or related service provider must submit claims for reimbursement on the CMS
1500 claim form or its successor. Reimbursement for hearing aids is made at the
lesser of the provider's billed charge, at the cost to the billing provider as
indicated by the manufacturer's, the distributor's or wholesaler's invoice,
which shall not exceed MAD's maximum reimbursement limitation amounts.
(1) Reimbursement for rental of hearing aids
includes the following:
(a) rental charge for
hearing aid; and
(b) hearing aid
mold and batteries.
(2)
Rental payments apply to the allowed amount for purchase. When the rental
payments equal the amount allowed for purchase, the aid is considered purchased
and owned by the MAP eligible recipient.
(3) Reimbursement for repairs to hearing aids
is based on the MAD fee schedule. Reimbursement for repairs to hearing aids
done by a manufacturer is the lesser of the provider's billed charge or the
manufacturer's charge for the repairs plus a predetermined handling fee. If
complications in securing the manufacturer's repair cause the provider to incur
handling costs exceeding the predetermined amount established by MAD, the
billing provider can be reimbursed for actual handling costs incurred if these
actual costs are adequately documented.
(4) Reimbursement is made for additional
accessories and supplies, including batteries, when required. Reimbursement is
made for an additional mold when a single aid type is used for both
ears.
(5) Reimbursement is made for
replacement ear molds.
(6)
Reimbursement for insurance for hearing aid loss and accidental damage is paid
at the lesser of the provider's billed charge or the maximum fee allowed by
MAD. If the insurance policy cost exceeds the maximum fee established by MAD,
reimbursement can be made at the actual policy rate if the actual cost is
documented.
(7) Hearing appliances
reimbursement limitations:
(a) Hearing aid
purchase: Hearing aid purchase is limited to one monaural or binaural purchase
per four year period with the following exceptions:
(i) a MAP eligible recipient under 21 years
of age and is subject to prior approval;
(ii) progressive hearing loss, such as
otosclerosis;
(iii) changes due to
surgical procedures;
(iv) traumatic
injury; and
(v) replacement of lost
hearing aid in accordance with his or her insurance coverage.
(b) Dispensing fees: The hearing
aid dispensing fee includes payment for the services listed below. If a
binaural dispensing fee is paid, it includes payment for all services listed
below for both hearing aids:
(i) hearing aid
selection and the fitting of the aids;
(ii) testing of the hearing aids;
(iii) one ear mold per hearing aid;
(iv) one package of batteries per hearing
aid;
(v) any other accessories
required to fit the aid;
(vi) all
follow-up visits and adjustments necessary for a successful fitting;
(vii) cleaning and adjustments for the life
of the aid; and
(viii) shipping and
handling.
(c) Hearing
aid evaluation: MAD covers the evaluation of a MAP eligible recipient for the
hearing aid, subject to the following limitations:
(i) the evaluation for hearing aid is not
payable to the same billing provider who bills for the hearing aid dispensing
fee incidental to the purchase of a hearing aid;
(ii) the evaluation for hearing aid is not
payable to a billing provider under the same corporate ownership as another
billing provider who bills for the hearing aid dispensing fee incidental to the
purchase of the hearing aid; therefore,
(iii) physicians and audiologists can be
reimbursed for audiologic and vestibular function studies in addition to a
dispensing fee.
