Section 426.416 - Reimbursable Services(A)Complete Audiological Evaluation. (1) Payment for a complete audiological evaluation will be made only if the evaluation is recommended by a physician;(2)Two Audiologists. The MassHealth agency will pay for two audiologists working together to perform an evaluation of an individual member under those circumstances where the knowledge, skills, and experience of the primary audiologist have identified a need for a second audiologist to aid in completing the initial test battery, such as for the testing of very young children or those with other pertinent developmental, physical, cognitive, or maturational factors. Circumstances warranting the services of two audiologists must be fully documented in the member's medical record. To receive full payment, both audiologists must use the appropriate service code and modifier combination listed in Subchapter 6 of the Audiologist Manual. The MassHealth agency pays one-half of the total reimbursement for two audiologists to each individual provider.(B)Hearing-aid Purchase. Payment for a hearing-aid purchase includes the following:(1) the hearing aid and standard accessories and options required for the proper operation of the hearing aid;(2) the proper fitting and instruction in the use, care, and maintenance of the hearing aid;(3) maintenance, minor repair, and servicing of the hearing aid that is furnished free of charge to non-MassHealth patients;(4) the initial manufacturer's warranty against loss or damage; and(5) the loan of a hearing aid to the member by the audiologist, when necessary.(C)Earmold. The provider may not claim payment for an earmold until the earmold has actually been delivered to the member. The date of service for the earmold is the date on which the earmold was delivered to the member. An earmold is not reimbursable if it is included in the manufacturer's price of the hearing aid or if the member already has an appropriate earmold. Payment for an earmold includes the following:(2) the proper fitting of the earmold; and(3) any adjustments that may be needed during the operational life of the earmold.(D)Ear Impression.(1)Ear Impression for an ITE/ITC Hearing Aid. Payment for an ear impression for a hearing aid includes one properly formed ear impression for each in-the-ear (ITE) or in-the-canal (ITC) hearing aid purchased. The provider may not claim payment for an ear impression for a hearing aid until the hearing aid has actually been delivered to the member.(2)Ear Impression for an Earmold for a BTE Hearing Aid. Payment for an ear impression for a hearing aid includes one properly formed ear impression for each behind-the-ear (BTE) hearing aid.(E)Batteries. Batteries must be new at the time of purchase.(F)Accessories. Payment for accessories and hearing-aid options includes proper fitting and adjustment of the accessory as needed. Accessories must be billed separately from the basic hearing-aid unit.(G)Major Repairs. The provider of a repair service is responsible for the quality of the workmanship and parts, and for ensuring that the repaired hearing aid is in proper working condition. The audiologist is responsible for ensuring that the repaired hearing aid is in proper working condition upon returning the aid to the member. Payment for a major repair to a hearing aid is limited to the following conditions.(1) All warranties and insurance must have expired.(2) The hearing aid must be sent directly to the repair facility or manufacturer that will perform the repair. (The handling charges of an intermediary are not reimbursable.)(3) The repair service must include a written warranty against all defects for a minimum of six months.(4) A copy of the invoice from the repair facility or manufacturer for the cost of the repair must be kept in the member's medical record.(H)Office Visits for Evaluation and Management Services. The MassHealth agency pays for an office visit for evaluation and management services only when one or more of the following services is required and is provided as part of the visit: (1) minor adjustments to the hearing aid to assure a proper fitting, such as an earmold adjustment, when the provider is not the provider who initially fit the hearing aid, and the provider who initially fit the hearing aid is no longer a MassHealth provider;(2) minor office repairs for which the provider customarily charges non-MassHealth members;(3) cleaning of the hearing aid; or(4) replacement of parts such as, but not limited to, tubing, hooks, battery doors, and recasing.(I)Refitting Services and Other Professional Services. The MassHealth agency pays for additional fitting/refitting services only where the hearing aid was dispensed more than one year prior to the date of service of the refitting services. These professional services include refitting of the aid, orientation, counseling with the member or member's family, contact with interpreters, fitting of a loaner aid, and similar services. Payment for these services must include a face-to-face encounter with the member.(J)Cochlear Implant Service Contract. The MassHealth agency pays for the following cochlear implant services:(1) A service or maintenance contract from the manufacturer of cochlear implant external components that is approved by the U.S. Department of Health and Human Services Food and Drug Administration (FDA), which covers certain costs for repair and replacement parts for an eligible member's existing cochlear implant external component and is subject to the provisions of 130 CMR 426.416(J)(2).(2) The following restrictions apply to the service contract:(a) The service contract must be for a minimum period of one year, paid in full with the enrollment. The MassHealth agency does not pay for a service contract purchased under an installment payment plan, where payment in full at enrollment is also an option.(b) The service contract, when available as a combined option, must include repair and replacement coverage for both the headpiece, controller, and processor.(c) The service contract is not covered until the manufacturer's original warranty, which is obtained at the time of initial implantation, expires.(d) A copy of the invoice from the manufacturer for the cost of the service contract must accompany the claim form.(e) The service contract must be between the manufacturer and the MassHealth participating provider supplying cochlear implant external services.(K)Replacement and Repair of Cochlear Implant External Components.(1) Replacement of a cochlear implant processor requires prior authorization in accordance with 130 CMR 426.408. Replacement of a cochlear implant processor is covered, only when: (a) the existing processor is obsolete; that is, the manufacturer no longer supports repairs on the existing processor; or(b) the existing processor is lost. A lost cochlear implant processor will be replaced by the same make/model as the lost processor, unless the processor is obsolete, in which case it would be substituted by the replacement model; and(c) the existing processor is beyond repair.(2) Replacement of cochlear implant external components, other than the cochlear implant external processor, are covered only when:(a) the existing component is lost. A lost cochlear implant component will be replaced by the same make/mode as the lost component.(b) the existing processor is beyond repair.(3) MassHealth covers repairs of cochlear implant external components.(4) The replacement or repair services must be performed in a cochlear implant clinic.Amended by Mass Register Issue S1277, eff. 1/2/2015.