Oregon Administrative Rules
Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS
Division 129 - SPEECH-LANGUAGE PATHOLOGY, AUDIOLOGY AND HEARING AID SERVICES
Section 410-129-0070 - Limitations

Universal Citation: OR Admin Rules 410-129-0070

Current through Register Vol. 63, No. 9, September 1, 2024

(1) Speech Language Pathology (SLP) services:

(a) Shall be provided by a practitioner as described in OAR 410-129-0065;

(b) Requirements for rehabilitative and habilitative therapy treatment:
(A) Require Prior Authorization (PA) when it exceeds one hour per day each for a group or individual;

(B) Shall be either group or individual and may not be combined in the authorization period; and

(C) Require PA after thirty (30) habilitative and thirty (30) rehabilitative visits per calendar year.

(c) The following SLP services are not subject to prepayment review (PPR) and do not require PA but are limited to:
(A) Two SLP evaluations in a 12-month period;

(B) Two evaluations for dysphagia in a 12-month period;

(C) Up to four re-evaluations in a 12-month period;

(D) One evaluation for speech-generating/augmentative communication system or device (SGD) shall be reimbursed per recipient in a 12-month period;

(E) One evaluation for voice prosthesis or artificial larynx shall be reimbursed in a 12-month period;

(F) Purchase, repair, or modification of electrolarynx;

(G) Supplies for speech therapy shall be reimbursed up to two times in a 12-month period, not to exceed five dollars each.

(d) The purchase, rental, repair, or modification of a SGD requires PA. Rental of a SGD is limited to one month. All rental fees shall be applied to the purchase price.

(2) Audiology and hearing aid services:

(a) All hearing services shall be performed by a licensed physician, audiologist, or hearing aid specialist;

(b) Binaural hearing aids shall be reimbursed no more frequently than every five (5) years for individuals age 21 and older who meet the following criteria and medical necessity: Loss of 35 decibel (dB) hearing level or greater in two or more of the following frequencies: 1000, 2000, 3000, and 4000 Hertz (Hz);

(c) Binaural hearing aids shall be reimbursed no more frequently than every three (3) years for children, birth through age 20, who meet the following criteria:
(A) Pure tone average of 25dB for the frequencies of 500Hz, 1000Hz, and 2000Hz; or

(B) High frequency average of 35dB for the frequencies of 3000Hz, 4000Hz, and 6000Hz.

(d) An assistive listening device may be authorized for individuals aged 21 or over who are unable to wear or who cannot benefit from a hearing aid. An assistive listening device is defined as a simple amplification device designed to help the individual hear in a listening situation. It is restricted to a hand-held amplifier and headphones;

(e) The following services do not require PA:
(A) One basic audiologic assessment in a 12-month period;

(B) One basic comprehensive audiometry (audiologic evaluation) in a 12-month period;

(C) One hearing aid examination and selection in a 12-month period;

(D) One pure tone audiometry (threshold) test; air and bone in a 12-month period;

(E) One electroacoustic evaluation for hearing aid; monaural in a 12-month period;

(F) One electroacoustic evaluation for hearing aid; binaural in a 12-month period;

(G) Hearing aid batteries - maximum of 60 individual batteries in a 12-month period. Clients shall meet the criteria for a hearing aid.

(f) The following services require PA:
(A) Hearing aids;

(B) Repair of hearing aids, including ear mold replacement;

(C) Hearing aid dispensing and fitting fees;

(D) Assistive listening devices;

(E) Cochlear implant batteries:

(F) Bone anchored hearing aid (BAHA) replacement components.

(g) The following services require PA and must meet medical necessity and medical appropriateness under Early and Periodic Screening, Diagnostic and Treatment (EPSDT):
(A) FM systems;

(B) Vibro-tactile aids;

(C) Earplugs;

(h) Services not covered:
(A) Adjustment of hearing aids are included in the fitting and dispensing fee and is not reimbursable separately;

(B) Aural rehabilitation therapy is included in the fitting and dispensing fee and is not reimbursable separately;

(C) Tinnitus masker.

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065 & ORS 414.025

Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.