7 AAC 43.927. Hearing services and items

(a) The department may enroll as a provider of hearing services and items an audiologist licensed under AS 08.11 who is practicing individually or in a group or a hearing aid dealer licensed under AS 08.55.

(b) Except as provided in (n) and (o) of this section, the department will pay for services and items that do not have a relative value unit (RVU) established for Medicare, adopted by reference in 7 AAC 43.108, at 80 percent of billed charges from enrolled providers in this state for the first nine billings that reflect a charge for an item or service not already on the schedule established under this subsection. Thereafter, the fee will be established based on the 50th percentile of the first 10 billings. The department will add new fees to the payment schedule each time the department receives 10 billings for an item or service not already on the schedule. To be paid under this subsection, a billing must reflect a charge that complies with the applicable standards in 7 AAC 43.040.

(c) The department will pay for services that have an RVU established for Medicare, adopted by reference in 7 AAC 43.108, and that are provided by an enrolled audiologist in accordance with 7 AAC 43.040, at 85 percent of the rate identified in the fee schedule established under 7 AAC 43.108. The department will calculate maximum allowable rates for covered services by using the factors and formula described in 7 AAC 43.108.

(d) The department will pay an enrolled audiologist for diagnostic, screening, preventive, rehabilitative, and corrective services and hearing items that are for a recipient referred by a physician, otologist, otolaryngologist, or other licensed health care practitioner if prescribing the services is within the scope of the practitioner's license.

(e) The department will pay an enrolled audiologist separately for cochlear implantation-related services, including

(1) a preliminary assessment;

(2) programming of the cochlear device;

(3) adjustments;

(4) education;

(5) auditory rehabilitation; and

(6) treatment sessions.

(f) The department will pay for an auditory rehabilitation evaluation session following a cochlear implantation

(1) on a one-session-per-month basis; and

(2) only if rendered by

(A) the audiologist, otologist, otolaryngologist, or physician who performed the cochlear implant procedure; or

(B) an enrolled health care practitioner practicing within the practitioner's license if referred by a practitioner in (A) of this paragraph who is unavailable,

(g) The department will pay an enrolled hearing aid dealer as follows:

(1) except as provided in (2) of this subsection, the department will pay for hearing services and items that are within the scope of the hearing aid dealer's license for a recipient referred by an audiologist, otologist, otolaryngologist, physician, or other licensed health care practitioner who has received training to administer hearing assessments and may prescribe the service or item as within the scope of the practitioner's license;

(2) the department will pay for a hearing aid if

(A) the hearing aid is prescribed by a physician; and

(B) the requirements of AS 08.55.060 (a) and (b) are met;

(3) the department will not pay an enrolled hearing aid dealer if the recipient has waived the hearing evaluation under AS 08.55.060 (c).

(h) The department will only pay for

(1) one hearing aid per ear, per recipient, per five calendar years, including the ear mold impressions and hearing instrument accessories; hearing instrument accessories include a

(A) single cord;

(B) Y-cord;

(D) new receiver; and

(E) bone-conduction receiver with headband;

(2) one dispensing fee per hearing aid;

(3) 20 hearing aid batteries per month up to 100 per year for a recipient for whom the department has paid for the rental or purchase of a hearing aid;

(4) 21 cochlear implant alkaline batteries per month; and

(5) 45 cochlear implant zinc air batteries per month.

(i) The department will pay an enrolled provider for the reasonable and necessary costs of delivery and dispensing expenses incurred in the delivery of the hearing items from the dispensing provider to the recipient if the recipient resides outside the municipality where the business of the enrolled servicing provider is located and the hearing aid or accessory is unavailable in the municipality in which the recipient resides. If the charges are over $50, the provider must submit

(1) an electronic claim, supported by

(A) the recipient's name;

(B) the recipient's address;

(D) the delivery date; and

(E) the itemized, total charges; or

(2) a paper claim, including an invoice that shows

(A) the recipient's name;

(B) the recipient's address;

(D) the delivery date; and

(E) the itemized, total charges.

(j) The department will pay separately for labor and repair parts for a damaged hearing aid, cochlear implant part, or accessory purchased by a recipient with the following limitations:

(1) the department will not pay more than $20 for each 15 minutes of labor costs;

(2) the billing for a repair part must reflect a charge that complies with the applicable standards in 7 AAC 43.040;

(3) labor and repair parts must be documented as necessary for the hearing aid, external cochlear implant part, or accessory to function as intended; documentation must include

(A) a statement signed by the recipient or the recipient's authorized representative that describes the cause for and nature of the repair;

(B) a description of the hearing aid, external cochlear implant part, or accessory being repaired and its serial number, if available;

(D) documentation for labor charges that includes the amount of time spent on the repair, rounded up to the nearest quarter hour, and the hourly rate charged for the repair;

(4) the department will not pay for labor and repair parts if the hearing aid, external cochlear implant part, or accessory is covered under a manufacturer's or supplier's warranty, or if the labor or repair parts are necessary to repair equipment that needs repair because of a manufacturer's defect.

(k) For rental or purchase of a hearing aid, the department will not authorize the rental of a hearing aid if the rental price would be more expensive than the purchase price. The department will pay an enrolled provider for the rental or purchase of a hearing aid as follows:

(1) for a rental period that is 30 days or longer, the department will pay a monthly rental fee that is equal to 10 percent of the allowed purchase price, as calculated under (b) of this section;

(2) for a rental period that is less than 30 days, the department will pay an amount equal to the monthly rental fee divided by the number of days in the month, times the number of days in the rental period;

(3) the department will not pay a rental fee for a rental period that exceeds 12 months of continuous use; if the length of need is more than 12 months of continuous use, the prescriber must administer another hearing assessment and request prior authorization for purchase of a new hearing aid; the department will pay the difference between the allowed purchase price and the total monthly rental fees already paid by the department if the provider

(A) transfers ownership of the hearing aid, including any warranty, to the recipient for whom it was rented; and

(B) replaces the rented hearing aid with a new hearing aid if the rented hearing aid was previously used by anyone other than the recipient before it was rented to the recipient;

(4) before the total rental fee payments equal the allowed purchase price, the department will not separately pay the cost of repairs and maintenance; repairs and maintenance must be included in the rental fee and must be documented in the rental agreement;

(5) when total rental payments reach the allowed purchase price of a new hearing aid, the department will pay the cost of repair and maintenance after 60 days or when the warranty expires, whichever is later.

( l ) The department will not pay a hearing aid dealer for a hearing test or diagnostic procedure designed to determine the cause of a hearing impairment.

(m) The department will not pay separately for administrative expenses. The following costs are considered administrative expenses and are included in the payment for the equipment:

(1) telephone responses to questions;

(2) mileage;

(3) travel expenses;

(4) travel time;

(5) equipment set up;

(6) installation;

(7) orientation and training regarding the proper use of equipment.

(n) The department will not separately pay a provider under this section for the initial external parts of a cochlear implant. For purposes of this subsection, those initial external parts consist of a

(1) microphone;

(2) speech processor; and

(3) transmitter.

(o) The department will not pay for the following devices identified as an assistive listening device in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2005, as amended from time to time and adopted by reference:

(1) a telephone amplifier;

(2) an alerter;

(3) a television amplifier;

(4) a television caption decoder;

(5) a telecommunications device for the deaf (TDD);

(6) a device for use with a cochlear implant.

(p) Prior authorization is required from the department before payment will be made for

(1)) the purchase of

(A) a semi-implantable, middle-ear hearing prosthesis;

(B) the following items and services identified as miscellaneous in Healthcare Common Procedure Coding System (HCPCS) 2005, as amended from time to time and adopted by reference in (o) of this section:

(i) a personal FM system, for a recipient under 21 years of age with hearing loss diagnosed by an audiologist licensed under AS 08.11;

(ii) an assistive listening device;

(iii) a hearing aid;

(iv) a hearing aid battery;

(v) a hearing aid accessory;

(vi) a hearing aid supply;

(vii) a hearing service;

(2) the rental of hearing aids;

(3) the purchase of a hearing aid, accessory, battery, or supply that exceeds the limit under (h) of this section; the department will not give prior authorization for more than two ear molds per ear per year;

(4) a payment request that exceeds the maximum allowable payment for an item;

(5) a customized hearing aid;

(6) a cochlear implant-related service under (e) of this section and accessory;

(7) an auditory rehabilitation evaluation session; and

(8) a digitally programmable or digital hearing aid.

(q) A request for prior authorization must be submitted electronically or in writing on a certificate of medical necessity, provided by the department. The request must include

(1) documentation of medical necessity by a licensed health care practitioner trained to administer hearing assessments and evaluations and practicing within the scope of the practitioner's license;

(2) manufacturer information;

(3) the item description or number;

(4) the global trade item number (GTIN), if available;

(5) the suggested list price; and

(6) the serial number, if available.

(r) In addition to the requirements of (q) of this section, a request for prior authorization for a cochlear implant must include

(1) results from a comprehensive audiological test and assessment administered by an audiologist, otologist, otolaryngologist, physician, advanced nurse practitioner, or licensed health care practitioner trained to administer hearing assessments and practicing within the scope of the practitioner's license; the results must show

(A) a diagnosis of bilateral moderate to profound sensorineural hearing impairment with limited benefit from a hearing aid;

(B) inconsistent audiometric findings, if any;

(D) a willingness by the recipient, or the recipient's guardian if the recipient is under 18 years of age, to undergo an extended program of rehabilitation;

(E) no known middle-ear infection or lesions in the auditory nerve and acoustic area of the central nervous system;

(F) an accessible cochlear lumen that is structurally suited to implantation; and

(G) no contraindications to surgery;

(2) X-rays and MRI reports; and

(3) results of a physical examination administered by a physician and completed within 12 weeks preceding the date of the prior authorization request.

(s) In addition to the requirements of (q) of this section, a request for prior authorization for an auditory rehabilitation evaluation session must include

(1) a documented treatment plan that is

(A) outlined in no less than six-month increments not to exceed 12 months; and

(B) signed by the audiologist, otologist, otolaryngologist, or physician who performed the cochlear implant surgery;

(2) the billing codes from the American Medical Association's Current Procedural Terminology (CPT) 2006, as amended from time to time and adopted by reference; and

(3) the charge amount indicated by each billing code for the requested sessions.

(t) In addition to the requirements of (q) of this section, a request for prior authorization for a payment request that exceeds the maximum allowable payment for an item must include a written statement that the recipient's condition requires the more costly item.

(u) In addition to the requirements of (q) of this section, a request for prior authorization for a replacement hearing aid or hearing aid accessory under (k) of this section must show that the item

(1) is necessary to replace an item that is under repair;

(2) is necessary to replace an item that has been in continuous use by the recipient for the item's reasonable useful lifetime; or

(3) is not covered by a manufacturer's warranty and is determined to be damaged as the result of a manufacturing defect.

(v) The department will give prior authorization if

(1) the request complies with (q) of this section;

(2) the request complies with (r) of this section, if applicable;

(3) the request complies with (s) of this section, if applicable;

(4) the request complies with (t) of this section, if applicable;

(5) the request complies with (u) of this section, if applicable; for a request under (u)(2) of this section, the department will give prior authorization only if the department determines that the item is lost or irreparably damaged;

(6) a less expensive alternative item is not available, if the

(A) request exceeds the maximum allowable payment for the item; or

(B) item is identified only as miscellaneous in Healthcare Common Procedure Coding System (HCPCS) 2005, as amended from time to time and adopted by reference in (o) of this section; and

(7) payment is appropriate under this chapter.

(w) The department may enter into a contract under AS 36.30, a grant, or another arrangement permitted by law, with an enrolled provider authorizing that provider to provide hearing aids, accessories, replacement cochlear implant parts, batteries, and supplies.

(x) In this section,

(1) "customized hearing aids" means hearing aids that are prescribed in accordance with this section and are uniquely constructed or substantially modified for a specific recipient;

(2) "miscellaneous" means an item or service listed in Healthcare Common Procedure Coding System (HCPCS) 2005, as amended from time to time and adopted by reference in (o) of this section, that is

(A) described as "miscellaneous," "not otherwise classified," or "not otherwise specified"; or

(B) without a specific description or identifier.

History: Eff. 9/1/94, Register 131; am 2/1/97, Register 141; am 10/12/97, Register 144; am 6/26/98, Register 146; am 5/5/99, Register 150; am 12/2/2005, Register 176; am 1/11/2006, Register 177

Authority: AS 47.05.010

Editor's note: The certificate of medical necessity referred to in 7 AAC.927(q) may be obtained from the Department of Health and Social Services, Division of Health Care Services, P.O. Box 110601, Juneau, Alaska 99811-0601; Internet address: http://www.hss.state.ak.us/dhcs/.

The American Medical Association's Current Procedural Terminology (CPT) 2006, as amended from time to time, and adopted by reference in 7 AAC 43.927(s) , may be obtained by contacting the American Medical Association at P.O. Box 930876, Atlanta, GA 31193, or by visiting their Internet address: https://catalog.ama-assn.org/Catalog/home.jsp. A copy is also available for examination at the Department of Health and Social Services, Division of Health Care Services, 350 Main St., Juneau, Alaska 99801.

The United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2005, adopted by reference in 7 AAC 43.927(o) , may be obtained by contacting the American Medical Association at P.O. Box 930876, Atlanta, GA 31193, or by visiting their Internet address: https://catalog.ama-assn.org/Catalog/home.jsp. A copy of the HCPCS is available for examination at the Department of Health and Social Services, Division of Health Care Services, 350 Main St., Juneau, Alaska 99801.

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