Covered and Noncovered Services : Covered Services and Requirements

Accessories

Providers may use procedure code V5267 (Hearing aid supplies/accessories) to bill for accessories.

Limits

The limits on hearing aid accessories are as follows, per Wis. Admin. Code § DHS 107.24(4)(g):

• All members: one harness, one CROS fitting, one new receiver per hearing aid, and one bone conduction receiver with headband per member per year
• Members age 18 and younger: three ear molds per hearing aid, two single cords per hearing aid, and two Y-cords per member per year
• Members over age 18: one ear mold per hearing aid, one single cord per hearing aid, and one Y-cord per member per year

An Overview

Hearing instruments consist of:

• ALDs.
• Hearing aids.
• Hearing aid accessories.

Both audiologists and hearing instrument specialists may dispense hearing instruments. As required by Wis. Admin. Code § DHS 107.24(3)(h)1, evaluation and testing for hearing instruments and modifications may only be performed by an audiologist for members who:

• Are cognitively or behaviorally impaired.
• Are 21 years of age or younger.
• Have special needs that would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist.

As specified in Wis. Admin. Code § DHS 107.02(2m), all hearing instruments require a prescription, except for:

• Accessories that are not part of an initial purchase.
• Hearing aid batteries.
• Repairs.

The written prescription must be maintained in the member's medical record. The prescription is good for one year.

ForwardHealth only covers medically necessary hearing instruments.

As a result of the Wisconsin biennial budget (2003 Wisconsin Act 33), which required Wisconsin Medicaid to implement a volume purchase plan for DME, the DMS signed volume purchase contracts with several hearing aid manufacturers. BadgerCare Plus will approve only the hearing aid models listed under each procedure code in the volume purchase contract. The volume purchase contract provides information regarding procedure codes, procedure code descriptions, purchase rates, and repair rates.

PA is not required for the dispensing of any covered hearing aid. Providers are reminded that PA is required for the purchase of any hearing aid.

The following table provides an overview of hearing aid policies:

Assistive Listening Devices

BadgerCare Plus only covers ALDs that meet the following criteria:

• The ALD has a standard amplifier.
• The ALD has one or two receivers (monaural or binaural earphones) with single or Y-cord.
• The system is battery operated (disposable battery).
• The system is portable.

Reimbursement for ALDs includes ear molds. Ear molds are not separately reimbursable.

Eligible members are limited to one ALD every five years.

Audiology Professional Services

As stated in Wis. Admin. Code § DHS 107.19, covered audiology services are those medically necessary screening, diagnostic, preventive, or corrective audiology services prescribed by a provider acting within the scope of their practice and provided by an audiologist.

Covered services include:

• Audiological evaluations, including:
  • Hearing aid or other ALD evaluations.
  • Pure tone air and bone conduction.
  • Speech thresholds and word recognition.
• Audiological tests. Other audiological tests may be used in conjunction with any evaluation technique when indicated.
• Audiometric techniques. Special audiometric techniques are defined as modifications of standard tests to suit the needs of members who are physically or developmentally disabled who cannot respond to standard or conventional audiologic techniques.
• Aural rehabilitation. Aural rehabilitation is defined as therapy services provided to a hearing impaired or deaf client in individual or group sessions, which generally fall into the following categories:
  • Auditory training. The systematic use of residual hearing potential to improve communication of persons with impaired hearing, with or without amplification.
  • Nonverbal communications. The process of assisting members to communicate through the use of non-verbal language such as Bliss symbols, signing, and finger spelling.
  • Speech/lip reading. The process through which a member, regardless of the state of his or her hearing, understands speech by carefully watching the speaker.
• Hearing aid or other ALD performance check.
• Impedance audiometry. [Acoustic immittance tests.]
• The following speech and language pathology services:
  • Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status.
  • Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual.
  • Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); group, two or more individuals.

Note: PA is required for coverage of some services.

Audiologists may provide hearing services to all eligible members. As required by Wis. Admin. Code § DHS 107.24(3)(h)1, evaluation and testing for hearing instruments and modifications may only be performed by an audiologist for members who:

• Are cognitively or behaviorally impaired.
• Are 21 years of age or younger.
• Have special needs that would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist.

Procedure Codes for Covered Services

Audiologists may provide services and submit claims for services that are defined by both HCPCS and CPT codes. For hearing instrument specialists, Wisconsin Medicaid will only reimburse claims submitted with HCPCS codes. Claims for services defined by CPT codes that are submitted by hearing instrument specialists will be denied.

Plan of Care

As stated in Wis. Admin. Code § DHS 107.19(3)(a), audiology providers are required to establish a written plan of care for all members prior to the provision of audiology services. The plan of care must include the physician's signature and must be maintained in the member's record.

The plan of care should be reviewed by the attending physician in consultation with the audiologist providing the active treatment or care at least every 90 days, per Wis. Admin. Code § DHS 107.19(3)(a).

Terms of Reimbursement

For diagnostic audiological services and for hearing therapy, the maximum allowable fees apply to one unit of service, which is the complete service as defined by the CPT code description.

BadgerCare Plus Postpartum Program Coverage

Pregnant members enrolled in BadgerCare Plus keep their health care coverage for 12 months after the end of their pregnancy, per 2025 Wisconsin Act 102. These members are eligible for all covered services during this postpartum period as part of their care.

Eligibility

Most full-benefit BadgerCare Plus or Medicaid members enrolled on their last day of pregnancy are eligible for an estimated 365 days of postpartum BadgerCare Plus coverage (The window of coverage occurs for 365 days through the end of the month in which the 365th day falls. For example, if the end of a qualifying member's pregnancy occurred on April 14, 2026, their postpartum coverage period would be complete on April 30, 2027).

If someone is already enrolled in BadgerCare Plus or Medicaid but does not report a pregnancy until after it has ended, they may still qualify for postpartum coverage, but they must be enrolled in the month in which the pregnancy ended.

If someone applies for coverage after their pregnancy has ended, they are eligible for 12-months of postpartum coverage if they obtain retroactive coverage for the month in which the pregnancy ended.

Exceptions

Members will not qualify for the 12-month BadgerCare Plus postpartum coverage period if any of these statements are true:

• They were enrolled in the BadgerCare Prenatal Program.
• They were only enrolled in BadgerCare through presumptive eligibility, also known as Express Enrollment.
• Their pregnancy ended before January 1, 2026.

Circumstances when coverage may end

The 12-month postpartum coverage period can end prior to the 12 months only if the member:

• Gained eligibility based on incorrect information or agency error.
• Asks to be disenrolled from coverage.
• Moves outside of Wisconsin.
• Dies.

Batteries

Batteries for Hearing Instruments

Wisconsin Medicaid reimburses providers for hearing instrument batteries when medically necessary and provided in accordance with specific claims submission instructions and limitations.

Prior authorization is required to request batteries beyond the battery quantity threshold as outlined in the DME Index and DMS Index.

A prescription is not required for hearing instrument batteries, per Wis. Admin. Code § DHS 107.02(2m).

Hearing instrument batteries are not included in the nursing home or home care daily rates and may be separately reimbursed.

Bone-Anchored Hearing Devices

ForwardHealth covers unilateral bone-anchored hearing device implant surgeries, bilateral bone-anchored hearing device implant surgeries, and bone-anchored hearing device implant surgeries for profound unilateral sensorineural hearing loss with normal hearing in the opposite ear when the following criteria for coverage are met.

Note: Providers (such as bone-anchored hearing device manufacturers, outpatient hospitals, ASCs, or rendering surgeons) are required to obtain separate Medicaid enrollment as a DME provider before submitting claims for bone-anchored hearing devices.

Coverage Criteria for Unilateral Bone-Anchored Hearing Device Implant Surgeries

ForwardHealth covers unilateral bone-anchored hearing device implant surgeries if all of the following criteria are met:

• The member is 5 years of age or older at the time of surgery.
• The member has sufficient bone volume and bone quality to support successful fixture placement as determined by the surgeon and the surgeon determines that the implant can safely be done in a one-step procedure.
• The member has a conductive and/or mixed hearing loss (unilateral or bilateral) with pure-tone average bone-conduction thresholds (measured at 0.5, 1, 2, and 3 kHz) less than or equal to 65 dB HL. The threshold range is intended to accommodate different degrees of hearing loss and corresponding output power of the bone-anchored hearing device.
• The member demonstrates an air-bone gap of at least 30 dB in the proposed implant ear.
• The member demonstrates a word recognition score greater than 60% via conventional air-conduction speech audiometry using single-syllable words.
• The member has one or more of the following conditions:
• Severe chronic external otitis or otitis media
• Chronic draining ear through a tympanic membrane perforation
• Malformation of the external auditory canal or middle ear
• Stenosis of the external auditory canal
• Ossicular discontinuity or erosion that cannot be repaired
• Chronic dermatologic conditions such as psoriasis of the ear canal
• Tumors of the external canal and/or tympanic cavity
• Other conditions in which an air-conduction hearing aid is contraindicated for the ear to be implanted, or where the condition prevents restoration of hearing using a conventional air-conduction hearing aid

Coverage Criteria for Bilateral Bone-Anchored Hearing Device Implant Surgeries

ForwardHealth covers bilateral bone-anchored hearing device implant surgeries if the following criteria are met:

• The member meets the unilateral bone-anchored hearing device criteria noted above for both ears and has symmetrical bone-conduction thresholds between ears. Symmetrical bone-conduction thresholds are defined as less than a 10 dB average difference between ears (measured at 0.5, 1, 2, and 3 kHz), or less than a 15 dB difference at individual frequencies.
• The member presents lifestyle needs that justify the need for binaural hearing via bone conduction.

Coverage Criteria for Bone-Anchored Hearing Device Implant Surgeries for Profound Unilateral Sensorineural Hearing Loss With Normal Hearing in the Opposite Ear

Note: Profound unilateral sensorineural hearing loss with normal hearing in the opposite ear is sometimes referred to as unilateral sensorineural deafness or SSD.

ForwardHealth covers bone-anchored hearing device implant surgeries for profound unilateral sensorineural hearing loss if the following criteria are met:

• The member has normal hearing in one ear, defined as a pure-tone average air-conduction threshold measured at 0.5, 1, 2, and 3 kHz of 20 dB HL or better.
• The member has average air-conduction thresholds measured at 0.5, 1, 2, and 3 kHz in the ear with the sensorineural hearing loss of 90 dB HL or poorer.
• The member is 5 years of age or older at the time of surgery.
• The member has sufficient bone volume and bone quality to support successful fixture placement as determined by the surgeon and the surgeon determines that the implant can safely be done in a one-step procedure.
• The member is mature enough and otherwise able to give accurate feedback on the effectiveness of the intervention during a trial period.

Non-Implant Bone-Anchored Hearing Devices

ForwardHealth covers non-implant bone-anchored hearing devices; however, PA is required.

Cochlear Implant Surgeries

Cochlear implant surgery to improve sensorineural hearing loss is covered by ForwardHealth when the following coverage criteria are met.

Coverage Criteria

General Coverage Criteria

ForwardHealth covers unilateral and bilateral cochlear implant surgery if all of the following criteria are met:

• Cochlear implant surgery is medically necessary and used to treat bilateral sensorineural hearing loss in adults or unilateral or bilateral sensorineural hearing loss in children under age 21.
• The member is cognitively and psychologically suitable for the implant.
• The member's hearing loss is not due to problems with the auditory nerve or with the central auditory nervous system.
• There are no medical contraindications to implantation, as determined by the cochlear implant team. Contraindications include, but are not limited to:
  • Deafness due to lesions of the eighth cranial (acoustic) nerve, central auditory pathway, or brain stem
  • Active or chronic infections of the external or middle ear and mastoid cavity
  • Tympanic membrane perforation
  • Cochlear ossification that prevents adequate electrode insertion as determined by the treating physician
  • Absence of cochlear development as demonstrated by CT scans
• There is radiographic evidence of cochlear development as demonstrated by a CT and/or MRI scan.
• The member's state of health permits the surgical procedure, as determined by a physician.
• The ear (right or left) is specified.

Coverage Criteria for Children

ForwardHealth covers unilateral or bilateral cochlear implant surgery under the following circumstances for children under age 21:

• The family has been properly informed about all aspects of the cochlear implant, including evaluation, surgical, and rehabilitation procedures.
• The member is scheduled to attend a concentrated oral and/or aural rehabilitation program recommended by the cochlear implant team through the Birth to 3 Program, local school, rehabilitation site, etc.
• For children under 12 months of age, a cochlear implant team has documented the medical necessity of implantation, and implantation is not medically contraindicated by current evidence-based research or anatomy development.
• For children 12 to 24 months of age, a cochlear implant team has documented the following:
  • Unilateral or bilateral severe to profound pre- or post-lingual sensorineural hearing loss, defined as a hearing threshold of pure-tone average of 70 dB hearing loss or greater at 500 Hz, 1000 Hz, and 2000 Hz.
  • A lack of progress in the development of auditory skills in conjunction with appropriate binaural amplification and participation in intensive auditory rehabilitation over a three-to-six-month period. Limited benefit from amplification may be quantified by measures including, but not limited to, the Meaningful Auditory Integration Scale or the Early Speech Perception Test.
• For children 24 months of age and older, a cochlear implant team has documented the following:
  • Unilateral or bilateral severe to profound pre- or post-lingual sensorineural hearing loss, defined as a hearing threshold of pure-tone average of 70 dB hearing loss or greater at 500 Hz, 1000 Hz, and 2000 Hz.
  • A lack of progress in the development of auditory skills in conjunction with appropriate binaural amplification and participation in intensive auditory rehabilitation over a three-to-six-month period. Limited benefit from amplification is defined and may be quantified as demonstrated by the following:
    • An aided score of 30% or less on the MLNT for children 24 months of age.
    • An aided score of 30% or less on the LNT for children 25 months to 5 years of age.
    • A test that may vary depending upon the child's cognitive and linguistic skills for children 5 years of age and older.

Coverage Criteria for Adults

ForwardHealth covers unilateral or bilateral cochlear implantation under the following circumstances for adults ages 21 and older:

• The member has a moderate to profound bilateral sensorineural hearing loss (50 dB or poorer averaged over 500-2000 Hz in the better ear).
• The member demonstrates limited benefit from amplification as defined by test scores of less than 50% correct in the best aided listening condition on recorded open-set sentence tests.

Documentation Requirements

The rendering surgeon must document all of the following in the member's medical record:

• Documentation that fully supports the coverage criteria
• Preliminary evaluations, diagnoses, and recommendations from a licensed otologist/otolaryngologist and audiologist that must occur within six months of the proposed implant date, prior to the cochlear implant team evaluation
• A pre-surgical team evaluation by a cochlear implant team, which may include otologists, otolaryngologists, audiologists, and experts from the speech-language pathology, psychology, social work, or deaf education disciplines
• Documentation of the cochlear implant team's current experience with cochlear implantation and with rehabilitation strategies
• Documentation of a post-surgical follow-up plan
• For simultaneous or sequential bilateral cochlear implantation, documentation that a unilateral cochlear implant plus a hearing aid in the other ear will not result in a sufficient bilateral hearing benefit (for those members, the hearing loss is to a degree that a hearing aid will not produce the required amplification)
• For placement of a second cochlear implant in the opposite ear requested more than 17 months after the initial implantation, documentation from the cochlear implant team supporting the evidenced-based clinical rationale

Facilities Must Be Medicaid-Enrolled Durable Medical Equipment Providers

Cochlear implant manufacturers, outpatient hospitals, and ASCs are required to obtain separate Medicaid enrollment as a DME provider before submitting claims for the cochlear implants.

Contracted Hearing Aid Models

As a result of the Wisconsin biennial budget (2003 Wisconsin Act 33), which required Wisconsin Medicaid to implement a volume purchase plan for DME, the DMS signed volume purchase contracts with several hearing aid manufacturers. BadgerCare Plus will approve only the hearing aid models listed under each procedure code in the volume purchase contract. The volume purchase contract provides information regarding procedure codes, procedure code descriptions, purchase rates, and repair rates.

Custom Ear Molds

A custom ear mold (V5264) for a behind-the-ear hearing aid is not included in the hearing aid package. A custom ear mold is separately reimbursable for the same DOS as the hearing aid purchase and should be submitted on the same claim. PA is not required for custom ear molds.

Definition of Covered Services

Dispensing

Wisconsin Medicaid may reimburse providers for hearing device dispensing fees. A hearing device can be a hearing aid or a non-implant bone-anchored hearing device. Medicaid-enrolled audiologists may dispense both hearing aids and non-implant bone-anchored hearing devices, and Medicaid-enrolled hearing instrument specialists may only dispense hearing aids.

For hearing aid styles that are available under contract, the provider may order only the models available under contract. The provider receives up to the maximum allowable fee for dispensing the hearing aid plus the contracted price for the specific hearing aid model.

For hearing aid styles that are not available under contract, the provider receives up to the maximum allowable fee for dispensing the hearing aid plus the lesser of the provider's net cash outlay (the manufacturer's invoice cost including end-of-month volume discounts) or the maximum allowable fee for the materials and supplies purchased.

Providers are required to indicate the dispensing fee HCPCS procedure code that most appropriately reflects the number of hearing devices dispensed. In addition, providers are required to bill their usual and customary charges for the dispensing of a hearing aid.

PA is not required for the dispensing and fitting of hearing aids.

The dispensing fee includes these services:

• A 12-month service guarantee and any necessary service to maintain proper function of the hearing aid
• Ear mold impression
• Initial office visit
• Proper fitting of the hearing aid
• Up to five post-fittings as necessary for adjustments and hearing aid orientation. (This includes performance checks.)

Wisconsin Medicaid only reimburses one dispensing fee per member, per ear, per 12-month period after the fitting of a hearing device.

Note: If an audiologist submits a claim for a dispensing fee, the audiologist may not submit a claim using CPT codes for the following services until after the original 12-month period dispensing service guarantee has expired:

• Initial office visit
• Proper fitting of the hearing aid
• Post-fittings as necessary for adjustments and hearing aid orientation, including performance checks
• Minor repairs
• Professional services associated with a major repair

Emergencies

Certain program requirements and reimbursement procedures are modified in emergency situations. Emergency services are defined in Wis. Admin. Code § DHS 101.03(52), as those services that are necessary to prevent the death or serious impairment of the health of the individual. Emergency services are not reimbursed unless they are covered services.

Additional definitions and procedures for emergencies exist in other situations, such as dental and mental health.

Program requirements and reimbursement procedures may be modified in the following ways:

• PA or other program requirements may be waived in emergency situations.
• Non-U.S. citizens may be eligible for covered services in emergency situations.

Hearing Aid Replacement

Equipment Failure and Loss or Damage Under Warranty

If, within 24 months of purchase, persistent repairs are required due to equipment failure, the manufacturer may choose to replace the hearing aid at no cost to the provider, member, or Wisconsin Medicaid. No further reimbursement will be made for the replacement hearing aid. However, if the manufacturer chooses to replace the hearing aid after the original 12-month dispensing service guarantee has expired, Wisconsin Medicaid will reimburse the additional dispensing fee. PA is not required for replacing a hearing aid that is covered under the equipment warranty. It is also not required for the dispensing of the replacement hearing aid.

Additionally, if during the loss and damage warranty or the equipment warranty the manufacturer replaces a hearing aid, the new model must be equal to or better than the original model. The replacement must include a full 24-month equipment warranty, which begins the date the provider receives the hearing aid.

Loss or Irreparable Damage Not Under Warranty

If a hearing aid is lost or damaged beyond reasonable repair and is no longer covered under a loss and damage warranty, providers are encouraged to request PA from ForwardHealth for a replacement hearing aid. Replacing a lost or damaged hearing aid is not restricted by a hearing aid's life expectancy.

Providers are required to include the following with PA requests for replacement of lost or damaged hearing aids:

• The provider's statement that the hearing aid is not covered by a manufacturer's loss and damage warranty
• Information regarding instructions given to the member on care and maintenance of a hearing aid so that a hearing aid is not lost or damaged in the future
• A statement from the member or member's caregiver regarding how the hearing aid was lost and the steps taken to recover the hearing aid
• A statement from the member or member's caregiver that insurance (for example, homeowners, property, renters) does not cover replacing the lost hearing aid, if applicable

Life Expectancy

If a hearing aid is no longer covered under warranty and needs to be replaced within five years of purchase (for example, the hearing aid was purchased over 24 months ago but less than five years ago), PA is required for the replacement.

Dispensing and Fitting

Wisconsin Medicaid only reimburses providers for one dispensing fee per member, per ear, per 12-month period after the fitting of a hearing aid. Wisconsin Medicaid will not reimburse an additional dispensing fee if a hearing aid is replaced within 12 months of the original dispensing date. Providers are required to indicate on claims the HCPCS procedure code that most appropriately reflects the number of hearing devices dispensed.

Noncontracted Hearing Aid Styles

For noncontracted hearing aid styles, the manufacturer determines the trial period, loss and damage warranty, equipment warranty, and repair warranty.

Interpretive Services

ForwardHealth reimburses interpretive services provided to BadgerCare Plus and Medicaid members who are deaf or hard of hearing or who have LEP. A member with LEP is someone who does not speak English as their primary language and who has a limited ability to read, speak, write, or understand English.

Interpretive services are defined as the provision of spoken or signed language communication by an interpreter to convey a message from the language of the original speaker into the language of the listener in real time (synchronous) with the member present. This task requires the language interpreter to reflect both the tone and the meaning of the message.

Only services provided by interpreters of the spoken word or sign language will be covered with the HCPCS procedure code T1013 (Sign language or oral interpretive services, per 15 minutes). Translation services for written language are not reimbursable with T1013, including services provided by professionals trained to interpret written text.

Covered Interpretive Services

ForwardHealth covers interpretive services for deaf or hard of hearing members or members with LEP when the interpretive service and the medical service are provided to the member on the same DOS and during the same time as the medical service. A Medicaid-enrolled provider must submit for interpretive services on the same claim as the medical service, and the DOS they are provided to the member must match. Interpretive services cannot be billed by HMOs and MCOs. Providers should follow CPT and HCPCS coding guidance to appropriately document and report procedure codes related to interpretive and medical services on the applicable claim form. Time billed for interpretive services should reflect time spent providing interpretation to the member. At least three people must be present for the services to be covered: the provider, the member, and the interpreter.

Interpreters may provide services either in-person or via telehealth. Services provided via telehealth must be functionally equivalent to an in-person visit, meaning that the transmission of information must be of sufficient quality as to be the same level of service as an in-person visit. Transmission of voices, images, data, or video must be clear and understandable. Both the distant and originating sites must have the requisite equipment and staffing necessary to provide the telehealth service.

Billing time for documentation of interpretive services will be considered part of the service performed. BadgerCare Plus and Wisconsin Medicaid have adopted the federal "Documentation Guidelines for Evaluation and Management Services" (CMS 2021 and 2023) in combination with BadgerCare Plus and Medicaid policy for E&M Services.

Most Medicaid-enrolled providers, including border-status or out-of-state providers, are able to submit claims for interpretive services.

Standard ForwardHealth policy applies to the reimbursement for interpretive services for out-of-state providers, including PA requirements.

Interpretive Services Provided Via Telehealth for Out-of-State Providers

ForwardHealth requirements for services provided via telehealth by out-of-state providers are the same as the ForwardHealth policy for services provided in-person by out-of-state providers. Requirements for out-of-state providers for interpretive services are the same whether the service is provided via telehealth or in-person. Out-of-state providers who are not enrolled as either border-status or telehealth-only border-status providers are required to obtain PA before providing services via telehealth to BadgerCare Plus or Medicaid members. The PA would indicate that interpretive services are needed.

Documentation

While not required for submitting a claim for interpretive services, providers must include the following information in the member's file:

• The interpreter's name and/or company
• The date and time of interpretation
• The duration of the interpretive service (time in and time out or total duration)
• The amount submitted by the medical provider for interpretive services reimbursement
• The type of interpretive service provided (foreign language or sign language)
• The type of covered service(s) the provider is billing for

Third-Party Vendors and In-House Interpreters

Providers may be reimbursed for the use of third-party vendors or in-house interpreters supplying interpretive services.

Providers are reminded that HIPAA confidentiality requirements apply to interpretive services. When a covered entity or provider utilizes interpretive services that involve PHI, the entity or provider will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity, and availability. Each entity or provider must assess what are reasonable and appropriate measures for their situation.

Limitations

There are no limitations for how often members may utilize interpretive services when the interpretive service is tied to another billable medical service for the member for the same DOS.

Claims Submission

To receive reimbursement, providers may bill for interpretive services on one of the following claim forms:

• 1500 Health Insurance Claim Form (for dental, professional, and professional crossover claims)
• Institutional UB-04 (CMS 1450) claim form (for outpatient crossover claims and home health/personal care claims)

Noncovered Services

The following will not be eligible for reimbursement with procedure code T1013:

• Interpretive services provided in conjunction with a noncovered, non-reimbursable, or excluded service
• Interpretive services provided by the member's family member, such as a parent, spouse, sibling, or child
• The interpreter's waiting time and transportation costs, including travel time and mileage reimbursement, for interpreters to get to or from appointments
• The technology and equipment needed to conduct interpretive services
• Interpretive services provided directly by the HMOs and MCOs are not billable to ForwardHealth for reimbursement via procedure code T1013

Cancellations or No Shows

Providers cannot submit a claim for interpretive services if an appointment is cancelled, the member or the interpreter is a no-show (is not present), or the interpreter is unable to perform the interpretation needed to complete the appointment successfully.

Procedure Code and Modifiers

Providers must submit claims for interpretive services and the medical service provided to the member on separate details on the same claim.

Procedure code T1013 is a time-based code, with 15-minute increments. Rounding up to the 15-minute mark is allowable if at least eight minutes of interpretation were provided.

Providers should use the following rounding guidelines for procedure code T1013.

Claims for interpretive services must include HCPCS procedure code T1013 and the appropriate modifier(s):

• U1 (Spoken language)
• U3 (Sign Language)
• GT (Via interactive audio and video telecommunication systems)
• 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system)

Providers should refer to the interactive maximum allowable fee schedules for the reimbursement rate, covered provider types and specialties, modifiers, and the allowable POS codes for procedure code T1013.

*Any telehealth service must be provided using HIPAA-compliant software or delivered via an app or service that includes all the necessary privacy and security safeguards to meet the requirements of HIPAA.

Dental Providers

Dental providers submitting claims for interpretive services are not required to include a modifier with procedure code T1013. Dental providers should retain documentation of the interpretive service in the member's records.

Allowable Places of Service

Claims for interpretive services must include a valid POS code where the interpretive services are being provided.

Federally Qualified Health Centers

Non-Tribal FQHCs, also known as CHCs, and Tribal FQHCs (POS codes 50 and XX), will not receive direct reimbursement for interpretive services as these are indirect services assumed to be already included in the bundled PPS (or AIR for Tribal FQHCs) rate. However, CHCs and Tribal FQHCs can still bill the T1013 code as an indirect procedure code when providing interpretive services. This billing process is similar to that of other indirect services provided by non-Tribal FQHCs. This will enable Wisconsin DHS to better track how CHCs and Tribal FQHCs provide these services and process any future change in scope adjustment to increase their PPS rate that includes providing interpretive services.

Rural Health Clinics

RHCs (POS code 72) receives direct reimbursement for interpretive services. Procedure code T1013 should be billed when providing interpretive services.

Interpreter Qualifications

The two types of allowable interpreters include:

• Sign language interpreters—Professionals who facilitate the communication between a hearing individual and a person who is deaf or hard of hearing and uses sign language to communicate
• Foreign language interpreters—Professionals who are fluent in both English and another language and listen to a communication in one language and convert it to another language while retaining the same meaning

Qualifications for Sign Language Interpreters

For Medicaid-enrolled providers to receive reimbursement, sign language interpreters must be licensed in Wisconsin under Wis. Stat. § 440.032 and must follow the specific requirements regarding education, training, and locations where they are able to interpret. The billing provider is responsible for determining the sign language interpreter's licensure and must retain all documentation supporting it.

Qualifications for Foreign Language Interpreters

There is not a licensing process in Wisconsin for foreign language interpreters. However, Wisconsin Medicaid strongly recommends that providers work through professional agencies that can verify the qualifications and skills of their foreign language interpreters.

A competent foreign language interpreter should:

• Be at least 18 years of age.
• Be able to interpret effectively, accurately, and impartially, both receptively and expressively, using necessary specialized vocabulary.
• Demonstrate proficiency in English and another language and have knowledge of the relevant specialized terms and concepts in both languages.
• Be guided by the standards developed by the National Council on Interpreting Health Care.
• Demonstrate cultural responsiveness regarding the LEP language group being served including values, beliefs, practices, languages, and terminology.

Medical Necessity

Wisconsin Medicaid reimburses only for services that are medically necessary as defined under Wis. Admin. Code § DHS 101.03(96m). Wisconsin Medicaid may deny or recoup payment if a service fails to meet Medicaid medical necessity requirements.

Member Payment for Covered Services

Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a noncovered service. (If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service.) If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.

If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions including termination of Medicaid enrollment.

Modifications

Providers are required to use procedure code V5014 (Repair/modification of a hearing aid) for all hearing instrument modifications.

Providers may receive reimbursement for one modification per hearing aid made by the manufacturer when the hearing instrument is purchased. Providers may receive reimbursement for modifications made only by the manufacturer. To receive reimbursement for the modification, providers must bill for it on the same DOS that the hearing instrument was dispensed. Providers must use modifier RT or LT on separate line items, as appropriate.

Note: BadgerCare Plus does not cover modifications within the first year of purchase beyond the one modification per hearing aid allowed at time of purchase; a one-year service guarantee is included under the warranty.

Examples of modifications to conventional hearing instruments include:

• Compression circuits
• Direct audio input
• Directional microphones
• Power circuit
• Special ear mold
• Telecoil

Examples of modifications to programmable or digital hearing instruments include:

• Automatic circuit features
• Multi-microphone system
• Multiple frequency bands (channels)
• Multiple memories
• Power circuit
• Special ear mold

Note: The hearing instrument modifications in this section may only be requested as modifications if they are not integral components of the basic hearing instrument.

Noncontracted Hearing Aid Models

Certain hearing aid styles (V5070, V5080, V5150, V5190, V5230) are not available through a volume purchase contract. For these hearing aid styles, providers are not limited to the models or manufacturers indicated in the lists of contracted hearing aid models and manufacturers. PA is required for the purchase of a hearing aid style that is not available through a volume purchase contract. Providers should refer to the maximum allowable fee schedule for these procedure codes. For noncontracted hearing aid styles, the manufacturer determines the trial period, loss and damage warranty, equipment warranty, and repair warranty.

Styles

The following procedure codes are allowable for hearing aid styles that are not available through a volume purchase contract. These procedure codes are allowable for members of any age:

Noncontracted Hearing Aid Models for Members Younger Than 21

If a hearing aid model that is not available through a volume purchase contract is medically necessary for a member younger than 21 years of age, PA is required. Audiologists will be reimbursed at the net cash outlay for the hearing aid. For these models, the net cash outlay for purchase is the manufacturer's invoice cost including end-of-month volume discounts.

Ordering a Hearing Aid from a Manufacturer

When ordering a hearing aid model that is available through a volume purchase contract for a Wisconsin Medicaid or BadgerCare Plus member, providers should indicate to the manufacturer that the hearing aid is for a Wisconsin Medicaid or BadgerCare Plus member.

Packages, Limitations, and Prior Authorization Requirements

Hearing Aid Package

The initial monaural hearing aid purchase includes an ear mold and cord. The initial binaural hearing aid purchase includes two ear molds and two cords. Batteries are not included in the initial hearing aid package.

Reimbursement

The purchase of a hearing aid package (including a hearing aid, ear mold, and cord) is reimbursed at the contracted price for the specific hearing aid model being dispensed. For hearing aid styles that are not available under contract, the provider receives reimbursement for the hearing aid package based on the lesser of the maximum allowable fee or the manufacturer's invoice cost including end-of-month volume discounts.

For hearing aid styles that are not available under contract, the provider is required to bill the manufacturer's actual invoice cost including end-of-month volume discounts. That amount is considered the net cash outlay or the actual cost to the provider. It allows the provider to fully recover their out-of-pocket cost for the purchase of the hearing aid furnished to members. Providers may be reimbursed for batteries under procedure code V5266.

Limitations

As stated in Wis. Admin. Code §§ DHS 107.24(4)(g) and (h), provision of hearing aid accessories shall be limited as follows:

1. For members under age 18: three earmolds per hearing aid, two single cords per hearing aid and two Y-cords per member per year;
2. For members over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per member per year; and
3. For all members: one harness, one CROS fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per member per year.

If a PA request is approved, the person shall be eligible for Medicaid reimbursement for the service on the date the final ear mold is taken.

Prior Authorization

These services require PA:

• Aural rehabilitation:
  • Use of residual hearing
  • Speech reading or lip reading
  • Compensation techniques
  • Gestural communication techniques
• Purchase of any special modifications to hearing instruments
• Purchase or rental of all hearing instruments
• Replacement of any hearing instruments not subject to the terms of the volume purchase contract
• SLP services provided by audiologists beyond the first 35 treatment days per calendar year
• Unlisted otorhinolaryngological service or procedure

BadgerCare Plus recognizes that a member's abilities, needs, and medical conditions are unique and have the potential to change. Therefore, approval of one PA does not guarantee approval of all PAs.

Conversely, a denied PA should not be interpreted to mean that services will not meet the definition of medical necessity in the future. Every PA request stands on its own merit, documenting the need for services and describing the member's unique circumstances at that time.

Custom Ear Molds

A custom ear mold (V5264) for a behind-the-ear hearing aid is not included in the hearing aid package. A custom ear mold is separately reimbursable for the same DOS as the hearing aid purchase and should be submitted on the same claim. PA is not required for custom ear molds.

Performance Checks and Returned Hearing Aids

According to Wis. Admin. Code § DHS 107.24(3)(h)2, providers are required to conduct a performance check for a hearing device 30 days after the dispensing date. Providers may only submit claims for a hearing device and the dispensing fee for a hearing device after the 30-day performance check has been conducted or, if the member does not return for a performance check, 45 days after the dispensing date. ForwardHealth calculates the number of days between the dispensing of the hearing device and the completion of the performance check by counting the calendar days between the "from" DOS for the hearing aid (entered on the claim by the provider) and the date the claim was submitted.

Contracted Hearing Aids

Contracted hearing aids include a 90-day trial period, which begins on the dispensing date. If a member is not satisfied with the hearing aid(s), the provider may return the hearing aid(s) to the manufacturer within the 90-day trial period. If the hearing aid is returned to the manufacturer during the 90-day trial period without being replaced and the provider has already been reimbursed by Wisconsin Medicaid, they are required to return the amount reimbursed, including reimbursement of the hearing aid and the dispensing fee, within 30 days of the hearing aid's return.

If a replacement is made, no refund is required. Because the original dispensing service guarantee is not expired, Wisconsin Medicaid will not reimburse an additional dispensing fee. In addition, no further reimbursement will be made for the replacement hearing aid.

Prescribed Services

As specified in Wis. Admin. Code §§ DHS 107.02(2m) and 107.19, BadgerCare Plus will only cover hearing services that are prescribed by a provider acting within the scope of their practice. In addition, all hearing instruments require a prescription, as stated in Wis. Admin. Code § DHS 107.24(2)(a), except for the following as noted in Wis. Admin. Code § DHS 107.02(2m):

• Accessories that are not part of an initial purchase
• Hearing aid batteries
• Repairs

The prescription must be in writing and kept in the member's permanent record.

Program Requirements

For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-enrolled provider to an enrolled member. In addition, the service must meet all applicable program requirements, including—but not limited to—medical necessity, PA, claims submission, prescription, and documentation requirements.

Recasing

Recasing or replacement of a hearing aid case is covered at a frequency of once per six-month period.

For recasing or replating performed on the same DOS as a major repair, providers should use procedure code V5014 for the major repair and V5014 with modifier 22 for the replating or recasing.

For recasing or replating of the hearing instrument, providers should use procedure code V5014 with modifier 22.

PA is not required for recasing or replating of a hearing aid case.

Service Units

For audiology services, one unit of service is the complete service as defined by the CPT code description. The provider's medical records must document that the service was completed on the DOS shown on the claim.

Services That Do Not Meet Program Requirements

As stated in Wis. Admin. Code § DHS 107.02(2), BadgerCare Plus and Wisconsin Medicaid may deny or recoup payment for covered services that fail to meet program requirements.

Examples of covered services that do not meet program requirements include the following:

• Services for which records or other documentation were not prepared or maintained
• Services for which the provider fails to meet any or all of the requirements of Wis. Admin. Code § DHS 106.03, including, but not limited to, the requirements regarding timely submission of claims
• Services that fail to comply with requirements or state and federal statutes, rules, and regulations
• Services that Wisconsin DHS, the PRO review process, or BadgerCare Plus determines to be inappropriate, in excess of accepted standards of reasonableness or less costly alternative services, or of excessive frequency or duration
• Services provided by a provider who fails or refuses to meet and maintain any of the enrollment requirements under Wis. Admin. Code ch. DHS 105
• Services provided by a provider who fails or refuses to provide access to records
• Services provided inconsistent with an intermediate sanction or sanctions imposed by DHS

Shipping

Shipping and handling is a non-covered service. The manufacturer covers the shipping expenses when a contracted hearing aid model is sent to the provider or returned to the manufacturer.

Trial Period

Contracted Hearing Aids

Contracted hearing aid models include a 90-day trial period. If a hearing aid is not satisfactory to the member, the provider may return the hearing aid to the manufacturer within 90 days of the dispensing date. The manufacturer will replace the hearing aid at no cost to the provider, member, or BadgerCare Plus. In order to assure that the member has adequately tried the hearing aid, the provider may not return the hearing aid sooner than 30 days unless there is apparent damage. PA is not required for hearing aids replaced by the manufacturer during the trial period.

Noncontracted Hearing Aids

For noncontracted hearing aid styles, the manufacturer determines the loss and damage warranty, equipment warranty, and repair warranty.

Unlisted Procedure Codes

Procedure Code 92599

Providers are to use CPT procedure code 92599 (unlisted otorhinolaryngological service or procedure) for services or procedures for which there is no specific CPT procedure code.

Procedure code 92599 should be used only when there is no other code that describes the service or procedure being offered. Only audiologists may request PA or submit claims for this code; PA requests and claims submitted by hearing instrument specialists will be denied.

PA is always required when using this code.

Procedure Code V5299

Use of HCPCS procedure code V5299 (hearing service, miscellaneous) is limited to those instances when there is no other code to describe a specific hearing instrument or supply. PA is still required when using procedure code V5299.

Providers must include this documentation when submitting PA requests for procedure code V5299:

• A complete description of the hearing instrument, including style, electroacoustic specifications, accessories, and the ear(s) to be fitted
• Comments addressing why the specialized hearing instrument requested with procedure code V5299 will provide measurable, significant improvement in functional hearing compared to a standard hearing instrument, a digitally programmable analog hearing instrument, or a digital hearing instrument
• Documentation verifying the cost, including a copy of manufacturer's information giving the list price
• PA/POR required for all PA requests by hearing instrument specialists
• PA/HIAS2

* Hearing instrument specialists are required to use the PA/POR for all PA requests for hearing instruments and supplies. Audiologists are not required to use the PA/POR; however, audiologists are required to maintain a record of medical clearance for the hearing instrument in the member's file.

Warranty and Repair

Contracted and Noncontracted Hearing Instruments

Dispensing Service Guarantee

A dispensing fee includes a 12-month service guarantee supplied by providers that starts on the dispensing date. During this 12-month period, providers should not submit claims to ForwardHealth for the following services related to the hearing device since provision of these services is included in the service guarantee:

• Adjustments
• Fittings
• Major repairs
• Minor repairs
• Orientation
• Performance checks

After the 12-month service guarantee expires, providers may submit claims to ForwardHealth for the above services, as applicable.

Contracted Hearing Instruments

Loss and Damage

Contracted hearing aid models are covered by the manufacturer under a 12-month loss and damage warranty.

Within 12 months of purchase, manufacturers are required to replace lost or damaged hearing aids at no cost to the provider, member, or Wisconsin Medicaid. No more than one loss or damage claim may be filed with the manufacturer per hearing aid during the 12-month period. No reimbursement will be made for dispensing the replacement hearing aid. PA is not required for replacing a hearing aid that is covered under the loss and damage warranty.

If a hearing aid is lost or damaged beyond repair more than once during the 12-month period, PA is required for the replacement hearing aid.

Equipment

Contracted hearing aid models are covered by the manufacturer under a minimum 24-month equipment warranty. The equipment warranty includes parts and labor. It does not cover the ear mold, cord, or batteries. Repairs needed within the equipment warranty time period will be made by the manufacturer at no cost to the provider, member, or Wisconsin Medicaid. PA is not required to repair a hearing aid that is covered under the equipment warranty. After the dispensing service guarantee expires, providers may submit claims to ForwardHealth for professional services associated with a major repair.

If, within the equipment warranty time period, persistent repairs are required due to equipment failure, the manufacturer may choose to replace the hearing aid at no cost to the provider, member, or Wisconsin Medicaid. No further reimbursement will be made for the replacement hearing aid. However, if the manufacturer chooses to replace the hearing aid after the original 12-month dispensing service guarantee has expired, Wisconsin Medicaid will reimburse the additional dispensing. PA is not required for replacing a hearing aid that is covered under the equipment warranty. It is also not required for the dispensing of the replacement hearing aid.

Replacement by the Manufacturer

If, during the loss and damage warranty or the equipment warranty, the manufacturer replaces a hearing aid, the new model must be equal to or better than the original model. The replacement must include a full 24-month equipment warranty, which begins the date the provider receives the hearing aid.

Repair

After the equipment warranty has expired, major repairs (V5014) completed by the manufacturer are allowed subject to the repair warranty.

Warranty lengths for repairs have been contracted separately for each hearing aid model and are indicated on the volume purchase contract. PA is not required for major repairs unless a second, unrelated repair is needed during the repair warranty. ForwardHealth covers major repairs once within the duration of the repair warranty. After the dispensing service guarantee expires, providers may submit claims to ForwardHealth for professional services associated with a major repair.

Repair rates are also contracted separately for each hearing aid model. When submitting claims for major repairs done on contracted hearing aid models, providers are required to indicate the contracted repair rate. Providers are reimbursed at the net cash outlay for major repairs done on contracted hearing aids; the net cash outlay for major repair is the contracted repair rate.

Minor Repair

After 12 months from the dispensing date for hearing aids purchased through a volume purchase contract, minor repairs (for example, repairs done in the office that involve care and cleaning) (V5014 with modifier 52) are allowed once every six months. Providers are required to bill their usual and customary charges for minor repairs. PA is not required for minor repairs unless a second repair is needed within six months of another minor repair.

Noncontracted Hearing Aids

Hearing aids purchased outside a volume purchase contract are not subject to the same requirements as those hearing aids purchased through a volume purchase contract. Hearing aids purchased outside a volume purchase contract include:

• Any hearing aid prior authorized before January 1, 2005.
• Any hearing aid purchased from the manufacturer before January 1, 2005.
• Any hearing aid that is prior authorized but is not available through a volume purchase contract.
• Any hearing aid that was not reimbursed by Wisconsin Medicaid.

After 12 months from the dispensing date of a hearing aid purchased outside a volume purchase contract, repairs are allowed once every six months. Wisconsin Medicaid will not reimburse:

• Major and minor repairs on items that are covered under warranty.
• Major and minor repairs on the same DOS for the same hearing aid.

For noncontracted hearing aid styles, the manufacturer determines the loss and damage warranty, equipment warranty, and repair warranty.