Section 426.408 - Prior AuthorizationServices 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 (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.Amended by Mass Register Issue S1277, eff. 1/2/2015.