CurrentBlue Cross Blue Shield - IowaPolicy H-5900-001-007

Hearing Services (WAHP) - NationsHearing administered benefits

Defines coverage, provider and billing rules, eligible services, and exclusions for hearing services offered to WAHP (Medicare Advantage) members in Iowa and South Dakota, including NationsHearing network administration.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyHearing Services (WAHP) - NationsHearing administered benefits

Policy CodePolicy H-5900-001-007

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review Date

Key ActionBill services on the CMS 1500 or 837 equivalent; out-of-network claims submit to NationsHearing and report codes to highest specificity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsfrequency allowance (per ear/year)

NationsHearingadministrative network

Multipleprocedure codes

IA, SDapplicable states

WAHP Hearing Services Coverage

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WAHP hearing services coverage criteria

Covered when ALL of the following conditions are met:

Applies to WAHP (Wellmark Advantage Health Plan) Medicare Advantage members in Iowa and South Dakota; WAHP may provide enhanced hearing benefits beyond Original Medicare and has contracted NationsHearing to administer some benefits.

ALL of the following

Eligible providers
- Primary care physicians (M.D. or D.O.)
- NationsHearing network providers

Benefit scope: Routine hearing services and hearing aids may be covered under WAHP (these are not covered by Original Medicare); prosthetic auditory implants or Medicare-covered diagnostic services remain subject to Medicare rules.

Frequency and allowance: Benefits are limited to per ear every 12 months (per ear every year).

Coding and diagnosis requirements: Claims must report the appropriate NationsHearing HCPCS/CPT codes or the listed Medicare CPT codes and ICD-10 audiology diagnosis codes to the highest specificity.

Reimbursement routing and member cost share: NationsHearing network providers will be reimbursed by NationsHearing; member cost share and specific maximum allowances are defined in the plan Evidence of Coverage (EOC) or Summary of Benefits (SOB); verify benefits and cost share with NationsHearing.

Purchase/location requirement: Hearing aids must be purchased from a NationsHearing provider based on the most recent audiometric examination and hearing aid evaluation test.

Procedure Codes and Benefit Frequency

NationsHearing HCPCS/CPT codesmixedCovered

92590-92592	Hearing services (NationsHearing)
V5008	Hearing aid fitting and related services
V5010	Hearing aid, monaural, behind-the-ear
V5011	Hearing aid, binaural, behind-the-ear
V5014	Hearing aid, monaural, in-the-ear
V5020	Hearing aid battery or accessory
V5030	Hearing aid supplies
V5040	Hearing aid supplies (duplicate entry from source)
V5050	Hearing aid, external component
V5060	Hearing aid component

1–10 of 55

1/6

Benefit Frequency / Allowance

Benefit frequencyPer ear every year (12 months)

Billing, Submission, and Medical Evaluation Requirements

Billing Rule

Billing and provider submission rules

Providers must bill using the CMS 1500 (02/12) claim form or the 837 equivalent. Out-of-network providers must submit claims to NationsHearing using the hearing services codes. Report CPT/CDT/HCPCS and diagnosis codes to the highest level of specificity. Providers with questions on filing for Medicare-covered exams and out-of-network exams may contact NationsHearing customer service at 1-877-271-1467.

Bill services on the CMS 1500 (02/12) claim form or the 837 equivalent claim form.
Out-of-network providers submit claims to NationsHearing using the hearing services codes.
Report CPT/CDT/HCPCS codes and diagnosis codes to the highest level of specificity.
Questions: NationsHearing customer service 1-877-271-1467

Documentation Required

Medical evaluation and Medicare-covered exam

A medical evaluation is required for members who have never had a hearing aid to determine the cause of hearing loss and whether it can be improved with a hearing aid. A Medicare-covered exam is a diagnostic hearing and balance evaluation performed by a physician, audiologist, or other qualified provider to determine if medical treatment is needed; these exams are covered as outpatient care. WAHP enhanced hearing services are in addition to Original Medicare benefits. The medical evaluation is covered under the base Medicare office visit benefit and member cost sharing may apply.

Medical evaluation required if member has never had a hearing aid.
Medicare-covered diagnostic hearing and balance exams are covered when furnished by a physician, audiologist, or other qualified provider.
Wellmark Advantage Health Plan (WAHP) enhanced hearing services are in addition to Original Medicare benefits.
Medical evaluation is covered under the base Medicare office visit benefit; member cost sharing may apply.

Key Terms

Conductive Hearing Loss

DefinitionConductive hearing loss affects the outer or middle ear and causes a barrier to sound transmission to the inner ear

Clinical courseMost conductive losses are not permanent and may be treatable with medication or surgery

Common causesExamples include total wax occlusion, otitis media, tympanic membrane perforation, and otosclerosis

Sensorineural Hearing Loss

DefinitionSensorineural hearing loss is caused by damage to the inner ear affecting outer and inner hair cells

PrognosisSensorineural hearing loss is permanent

Primary managementBest addressed by fitting of hearing aids for sound stimulation

Original Medicare Exclusion

Original Medicare coverageHearing aids and examinations for prescribing, fitting, or changing hearing aids are excluded from coverage under Original Medicare

Medicare-covered prosthetic devicesCertain devices (cochlear implants, auditory brainstem implants, osseointegrated implants) may be payable as prosthetic devices when hearing aids are medically inappropriate

Applicable guidanceExclusion is per Code of Federal Regulations and CMS guidelines