- Why are hospital outpatient departments reimbursed for audiology services, but Medi-Cal providers in private practice that perform the identical services not reimbursed?
A: Federal law requires Medi-Cal to cover hospital outpatient services if the service(s) are generally furnished by most hospitals in the state.
- Are there any exemptions to the Optional Benefits Exclusion (OBE) policy specifc to audiology services?
A: Yes. In addition to the exemptions as noted in FAQ#2 of the OBE: FAQs – General
category, the following Medi-Cal benefits are not impacted by the OBE policy:
- Beneficiaries with a cochlear implant will continue to receive necessary services related to the cochlear implant.
- Hearing aids, hearing aid accessories and batteries. Please note that hearing aid batteries are only covered for EPSDT eligible beneficiaries.
- Newborn Hearing Screening Program services
- "Most claims for excluded optional benefit services billed by a physician or physician group remain reimbursable on or after July 1, 2009." Does this mean that a physician who employs an audiologist or a speech pathologist can bill for their work under the physician’s billing ID?
A: No. The rendering provider must be a physician.
- If a Treatment Authorization Request (TAR) was approved for an audiology service (such as a hearing test) was obtained before July 1, 2009, will Medi-Cal cover the approved services if they are performed after June 30, 2009?
A: Yes. All excluded optional services that have a TAR approved prior to July 1, 2009 will remain reimbursable after June 30, 2009 and up to the end date of the approved TAR.
- Is code V5014 (hearing aid cleaning and adjusting) reimbursable on or after July 1, 2009?
A: Yes. V5014 will remain reimbursable to all beneficiaries.
- Are the following codes remain reimbursable on or after July 1, 2009: V5010 (hearing aid evaluation); V5014 (hearing aid repairs); X4542 and X4532 (electroacoustic analysis of hearing aids)?
A: V5010, V 5014, X4542 and X4532 are not
exemption criteria is met as outlined in the Optional Benefits Exclusion
section of the Part 2 provider manual. The list of audiology codes that will remain reimbursable for cochlear implant beneficiaries are also listed in the OBE section.
- Can audiology service providers charge any fee to Medi-Cal beneficiaries for rendering services that are no longer a benefit?
A: Yes. Since optional benefits are no longer a covered by the Medi-Cal program, Medi-Cal has no control of how much the provider may charge a beneficiary.
- Will codes V5264 (ear molds) and V5267 (hearing aid supplies/accessories) continue to be a covered benefit?
- Please clarify whether all hearing aids are exempt or just hearing aids for newborns?
A: All hearing aids will remain a benefit.
- Will code X4526 (hearing therapy) still be covered on or after July 1, 2009?
A: X4526 will remain reimbursable for all beneficiaries who receive a cochlear implant.
- Will codes X4530 (acoustic reflex testing), X4500 (audiometric evaluations) and X4540 (tympanometry) still be covered on or after July 1, 2009?
A: X4530 is not a billable code for Medi-Cal. Codes X4500 and X4540 are no longer reimbursable effective July 1, 2009 unless rendered to an exempt beneficiary as noted in FAQ#2 on the OBE: FAQs – General
- If medical audiological treatments and surgeries are excluded benefits, are pre- and post-operative evaluations also excluded?
A: Only post-cochlear implants codes will remain reimbursable for all beneficiaries. Please refer to the appropriate Part 2 provider manual for the list of audiology codes that will remain reimbursable for post-cochlear implant beneficiaries. Pre-operative evaluations are no longer covered benefits.
- The Medi-Cal benefits reduction notice states: "Some of these benefits and services may be continued if you are currently receiving them." Does that mean an audiologist can continue to bill Medi-Cal for providing services to beneficiaries treated for hearing loss with hearing aids and related services such as audiometry?
A: No. Although there is a provision for a continuing care exemption, it only applies to medical and/or surgical care required for the treatment and the resolution of an acute episode.
- Many children are seen for hearing tests that have some sort of Medi-Cal managed care such as the Santa Clara Family Health Plan or Healthy Families. Are these children still going to be able to get hearing tests covered because of the “under the age of 21” policy exception?
A: Yes. EPSDT-eligible beneficiaries under 21 years of age with full-scope Medi-Cal benefits are an exempt group. They can still get all medically necessary hearing tests and evaluations even if they belong to Medi-Cal managed care or Healthy Families health plans. Please contact the appropriate managed care plan for more information.
- What are "sub-acute" care facilities?
A: Sub-acute care facilities are considered to be Skilled Nursing Facility Level B (NF-B). All beneficiaries receiving long term care in an NF-B are exempted and will continue to receive the excluded optional benefits.
- Can providers bill for audiological services rendered to beneficiaries living in a
skilled nursing facility (SNF), intermediate care facility (ICF), an intermediate care faciliy for the developmentally disabled (ICF-DD) or a sub-acute facility?
A: Yes. Beneficiaries are not required to physically receive the services in the facility. However, the provider must include the National Provider Identifier (NPI) of the facility in the referring provider box of the claim.