Audiology
Health First Colorado (Colorado's Medicaid program) 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.
What services are available?
A variety of Current Procedural Terminology (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
- 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.
- 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.
How do I become an enrolled provider?
As a Health First Colorado 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. Visit the Why Become a Provider? web 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 Enhanced Ambulatory Patient Grouping (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.
Visit the Provider Resources web page for resources on enrollment and billing.
- Refer to the Provider Bulletin Index located on the Bulletins web page for 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 on the NCCI web page on the Centers for Medicare & Medicaid Services website, including the NCCI Policy Manual found there.
How are newborn hearing screens reimbursed?
- For inpatient hospital deliveries, reimbursement for newborn hearing screening is included in the hospital Diagnosis-Related Group (DRG) for the delivery. Follow-up screening for a failed initial screening is covered outside of the hospital DRG payment. Refer to the Audiology Benefit Billing and Policy Manual for complete details.
Are Bone-Anchored Hearing Aids covered?
Which services require Prior Authorization?
- Bone Anchored Hearing Aids require prior authorization. Visit the ColoradoPAR: Health First Colorado Prior Authorization Request Program web page for more information.
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
- Questions about claims and billing must be directed to Gainwell Technologies. Visit the Provider Contacts web page for a list of resources.
- Questions about policy and coverage may be directed to the program administrator. Contact Devinne Parsons at Devinne.Parsons@state.co.us.
