Audiology

Health First Colorado covers audiology services and devices. This includes hearing exams and hearing aids for specific age groups. Services take place in the office, hospital, home, and other settings.

Who is eligible for audiology services?

All enrolled members are eligible to receive these services, however specific limitations apply to certain procedures and devices.

Reference the billing and policy manual for complete details.

What services are available?

A variety of CPT billing codes are available for billing. These include but are not limited to:

• Hearing exams
• Hearing aids, including batteries and replacement parts
• Cochlear implants
• Newborn hearing screens

 

Reference the billing and policy manual for complete details.

General Policies

• All services must be medically necessary.
• All claims must include the National Provider Identification (NPI) number of the enrolled provider who rendered the service.
• There are generally no co-pays applicable to this benefit. Co-pays are only required if the member is being treated in a hospital setting and is not a child (under age 19) or pregnant woman.

Reference the billing and policy manual for complete details.

What services are not covered?

• The upgrading of an existing cochlear implant system or component if the existing unit is properly functioning is not covered.
• Hearing aids and cochlear implants for adults (ages 21+) are not covered.
• Cochlear implant replacement component(s) of an existing cochlear implant is a benefit for all ages when the currently used component(s) is no longer functional and cannot be repaired.
• Hearing exams and evaluations are a benefit for adults (ages 21+) are covered only when a concurrent medical condition exists.
• Hearing aid insurance is not covered.
• Ear molds for the purpose of noise reduction or swimming are not covered.

Reference the billing and policy manual for complete details.

How do I become an enrolled provider?

As a Health First Colorado (Colorado's Medicaid Program) provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance - it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.

The enrollment process is online and begins on the Become a Provider page.

Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.

How are services reimbursed?

Audiology services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to 'lesser-of' pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.

Hospital providers of audiology services are subject to EAPG reimbursement methodology.

Providers must first enroll into the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.

Resources for enrollment and billing may be found at Provider Resources.

Recent News and Updates

• Check the Provider Bulletin indexfor all provider bulletins related to the audiology benefit.
• National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information found on the Medicaid.gov NCCI Website, including the NCCI Policy Manual found there.

Frequently Asked Questions

How are newborn hearing screens reimbursed?

• For inpatient hospital deliveries, reimbursement for newborn hearing screening is included in the hospital DRG for the delivery. Follow-up screening for a failed initial screening is covered outside of the hospital DRG payment. See the billing and policy manual for complete details.

Are Bone Anchored Hearing Aids covered?

• Yes, only for children. See the billing and policy manual for details.

Which services require Prior Authorization?

• Bone Anchored Hearing Aids require prior authorization. The process begins at the ColoradoPAR web page.

Policy Documents

• Audiology Billing and Policy Manual (revision December 2020)

Applicable Rules, Regulations, and Statutes

All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specifically called out as the ones governing the audiology benefit:

• 42 CFR 440.110 - Federal regulation describing the minimum requirements for a State Medicaid Agency to cover audiology.
• 10 CCR 2505-10 8.200 and 8.300

Contact Information

• Questions about claims and billing must be directed to Gainwell Technologies. A list of resources is available at /provider-help
• Questions about policy and coverage may be directed to the program administrator. Contact Devinne Parsons at Devinne.Parsons@state.co.us.