471 Neb. Admin. Code, ch. 8, § 004

Current through September 17, 2024

Section 471-8-004 - SERVICE REQUIREMENTS

004.01GENERAL REQUIREMENTS.

004.01(A)MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity from 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

004.01(B)PRIOR AUTHORIZATION. Medicaid requires prior authorization for certain items and services, as outlined on the Nebraska Medicaid Hearing Aid Fee Schedule.

004.01(B)(i)PRIOR AUTHORIZATION PROCEDURE FOR HEARING AIDS, ASSISTIVE LISTENING DEVICES, AND ACCESSORIES. Medicaid requires that the following information be submitted when requesting prior authorization for all hearing aids and assistive listening devices billed at $ 500.01 or greater per unit, and accessories of $150 or greater per line item:

(a) A complete audiogram;

(b) The name of the examiner or dispenser performing the audiogram;

(c) The type of hearing aid or assistive listening device being recommended and any accessories;

(d) The estimated cost of the hearing aid or assistive listening device;

(e) The estimated cost of each item being provided;

(f) The hearing aid dispenser's provider number; and

(g) The hearing aid dispenser's name, address and phone number.

004.01(B)(i)(1)PRIOR AUTHORIZATION FORM. Form DM-5H, Physician's Report on Hearing Loss, must be used when submitting a request for prior authorization. All requests for prior authorization, and supporting documentation, must be submitted to the Department or the utilization management organization under contract with the Department.

004.01(B)(ii)PRIOR AUTHORIZATOIN PROCEDURE FOR REPAIRS. All requests for prior authorization, and supporting documentation, must be submitted to the Department or the utilization management organization under contract with the Department. Medicaid requires that the following information be submitted when requesting prior authorization for all repairs of $150 or greater per line item:

(1) The estimated cost of the repair;

(2) The estimated cost of each item being provided;

(3) The hearing aid dispenser's provider number; and

(4) The hearing aid dispenser's name, address and phone number.

004.01(C)EAR, NOSE, AND THROAT (ENT) EVALUATIONS. Medicaid requires that a client be evaluated by a licensed otolaryngology specialist who is an approved Medicaid provider when the following criteria is met:

(i) The client has a conductive hearing loss;

(ii) The client has a unilateral hearing loss;

(iii) The client has asymmetric hearing loss;

(iv) The client reports dizziness; or

(v) The client is age 16 or younger.

004.01(D)SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(E)HEALTH CHECK SERVICES. See 471 NAC 33

004.02COVERED SERVICES. Medicaid provides hearing aids and supplies to Nebraska Medicaid eligible clients. These services include hearing aids, hearing aid repairs, assistive listening devices, and other hearing aid services when the services are medically necessary and are prescribed by a physician. Medicaid covers in-the-ear (ITE), behind the ear (BTE), in the canal (ITC), completely in the canal (CIC), or receiver in the canal (RIC) hearing aids. Bone conduction aids will be approved with ear, nose, and throat (ENT) physician approval.

004.02(A)NUMBER OF HEARING AIDS. Medicaid covers:

(i) For clients age 20 and younger, the number of hearing aids is dependent on medical necessity; and

(ii) For clients age 21 and older, hearing aids are limited to not more than one aid per ear every four years and then only when medically necessary. Medical necessity is determined using the prior authorization procedure in this chapter.

004.02(B)REPLACEMENT OF HEARING AIDS AND ASSISTIVE LISTENING DEVICES. The provider must obtain prior authorization from Medicaid for all replacements of lost or stolen hearing aids or assistive listening devices.

004.03NON-COVERED SERVICES. Medicaid does not cover:

(A) Hearing aid batteries for residents of a nursing facility except with the initial fitting;

(B) Accessories which are for convenience; or

(C) Items that are deemed to be not medically necessary.

471 Neb. Admin. Code, ch. 8, § 004

Amended effective 10/9/2021