Prior Authorization

(A) Services designated "P.A." in the list of service codes and descriptions in Subchapter 6 of the Hearing Instrument Specialist Manual require prior authorization from the MassHealth agency. The MassHealth agency requires prior authorization for: (1) any hearing aid that costs more than the amount indicated in the applicable service description in Subchapter 6 of the Hearing Instrument Specialist Manual; (2) the replacement of a hearing aid consistent with the provisions of 130 CMR 416.418, regardless of the cost of the hearing aid, due to: (a) a medical change; (b) loss of the hearing aid; or (c) damage beyond repair to the hearing aid; and (3) certain hearing aid related services as specified in Subchapter 6 of the Hearing Instrument Specialist Manual. (B) The MassHealth agency requires the following documents from the provider requesting prior authorization for replacement of hearing aids, or certain hearing aid related services, as applicable: (1) the audiological evaluation required under 130 CMR 416.414(A); (2) the previous audiological evaluation if the replacement hearing aid is needed because of a medical change; (3) a comprehensive report that justifies the medical necessity for the hearing aid; (4) a statement of the circumstances of the loss or destruction of the hearing aid (where applicable); (5) the medical clearance required under 130 CMR 416.414(B); and (6) an itemized estimate of the anticipated cost of the hearing aid. (C) All prior-authorization requests must be submitted in accordance with the administrative and billing instructions in Subchapter 5 of the Hearing Instrument Specialist Manual. Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment.