FAQ Index
Index of all Reimbursement FAQs
Disclaimer: The information provided in this reimbursement site is provided as a set of guidelines only to address the unique nature of implantable hearing solutions technology and is not intended as legal advice. There is no guarantee that following these guidelines will result in any form of coverage or reimbursement from any insurance company or federal health care program payer. The information presented herein is subject to change at any time and may become outdated. This information cannot and does not contemplate all situations that the health care professional/provider may encounter. To be sure that you have the most current and applicable information available for your unique circumstances, please consult your own coding advisors, and payers to verify that the information provided herein is applicable to your needs. Seek your own legal advice regarding your reimbursement needs and the proper implementation of these guidelines. All products should be used according to their labeling. In all cases, services billed must be medically necessary, actually performed, and appropriately documented in the medical record.
Commercial / Private Insurance
- What are the major differences between a HMO and PPO plan?
- If the plan has a medical policy stating that a specific device meets their “medical necessity” requirements for coverage does this mean that every patient who has that specific health plan has coverage for this device?
- How can an audiologist, patient, or physician find out whether a patient has coverage for a specific device, procedure, or service?
Payment Methodologies
- Will the Explanation of Benfits (EOB) provide information on whether the service is covered?
- Can I be charged the difference between a health plan allowable and what my doctor bills?
- What does it mean if a payer’s fee schedule is “based on Medicare”?
- Which payment methodology is used to pay for cochlear implants (CI) and Baha®?
Coding - General
- What are the differences between CPT and HCPCS codes?
- Should we use ICD-9 or ICD-10?
- Why are we switching from ICD-9 to ICD-10?
- Can L codes be billed without a Durable Medical Equipment License?
- What are V codes?
- What is a “DRG code”?
- What are modifiers and how are they applicable to implantable hearing solutions?
Coding and Billing
- We are starting a new Baha® program. Do payers cover Baha?
- Cochlear implants and Bahas are medical devices, how can we make sure we get appropriate reimbursement to cover these costs?
- Ambulatory surgery centers (ASCs) have not traditionally performed many procedures involving implantable medical devices. Can we be reimbursed for those procedures?
- How do I know if my patient is eligible for an upgrade replacement of the patient’s Cochlear-provided sound processor for either cochlear implants or the Baha?
- Is there a limit to number of sessions or frequency for cochlear implant mapping/programming?
- What codes am I allowed to bill together? It seems I get frequent denials for certain combinations of codes.
- Are there any codes for neural response telemetry (NRT)?
- How do we code for a Baha abutment change? Can we do this service in the office setting?
Federal-State (Medicare/Medicaid)
- A Medicare-only patient is interested in having the cochlear implant or Baha® surgery. Which part of the Medicare benefits will cover the surgery?
- A Medicare patient needs replacement parts for a cochlear implant or Baha. Who covers this?
- Why do Medicare Advantage plans (HMOs, PPOs) require prior authorization?
- Will Medicare cover bilateral cochlear implants?
- Does a Medicare HMO have to provide the same coverage as Medicare?
- Will Medicaid follow the same coverage benefits as Medicare?
- Is the Federal Employee Health Benefits Program a public plan like Medicare?
- When will Medicaid be billed as the primary payer?
- Why do some patients have Medicaid plans that are affiliated with health plans?
- Do state Medicaid plans require prior authorizations?
- Do Medicaid managed care plans work similarly to commercial managed care plans?
- How often does the patient or their family need to reapply to Medicaid?
- Can Medicaid supplement a commercial health plan?
Medical Management
- Why should a patient or provider obtain a predetermination if a prior authorization is not required?
- When is it appropriate to appeal a denial?
- What is a referral? When do I need one?
- What authorizations are required for Nucleus® Cochlear™ Implant and/or Baha® surgery?
- How soon does the commercial health insurance need to provide an answer of whether an implantable hearing procedure or service is "medically necessary?"
- What happens if the provider has already obtained prior authorizations and the cochlear implant and/or Baha surgery date has changed?
- How do providers find out the basis for the health plan's denial of implantable hearing services/procedures?
- What is the Managed Care Reform Act?
- If the patient has Medicare and a commercial health insurance plan, are providers still required to obtain authorizations for the implantable hearing services/ procedures provided?
- If the patient has two health plans, do they need an authorization from both?
- I have an individual plan that has a pre-existing clause. Is there any way of getting around that?
Compliance / Other Key Definitions
Last update: 09/30/10
