2.0 Audiology equipment and supplies benefits list

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2.1 General information

2.1.1 Benefit Policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

2.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB for the specific item will lead to denials or reversals of claims.

NIHB recognized prescribers/recommenders include:

  • AUD — Audiologist
  • ENT — Otorhinolaryngologist / Otolaryngologist
  • HIPFootnote 1 — Hearing Instrument Practitioner or Audio-prosthetist or Hearing Aid Dispenser
  • MD — Physician
  • NP — Nurse Practitioner

NIHB recognized providers include:

  • AUD — Audiologist
  • GEN — Enrolled general MS&E and Pharmacy Provider
  • HIP — Hearing Instrument Practitioner or Audio-prosthetist or Hearing Aid Dispenser

2.1.3 Prior Approval Requirements

General prior approval requirements can be found in the general policies

To initiate the prior approval process; complete the NIHB Audiology Prior Approval Form, found on the Express Scripts Canada website, and submit to the NIHB regional office along with the following supporting documentation:

  • the prescription/recommendation or referral form signed by a NIHB recognized prescriber for the requested benefit
  • the most recent audiometric test or an audiology assessment report which must be less than 6 months old. An audiometric test is not required for the replacement of a cochlear implant (CI) processor.
  • additional relevant information the provider, physician, nurse practitioner, or audiologist may have to support the request
  • an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plans, etc.)

Audiometric tests must be performed by either:

  • an Audiologist
  • a Hearing Instrument Practitioner or Audio-prosthetist

Repairs require the following information on the prior approval request:

  • manufacturer name
  • model number or name
  • date fitted
  • serial number
  • description of the problem requiring the repair service
  • expiration date of the hearing device warranty

2.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the audiology benefit and are not considered for coverage or appeal under the NIHB program:

  • items used exclusively for education/school
  • surgical implants (internal device for CI and bone-anchored hearing system (BAHS))
  • hearing protectors used in work-related situations
  • therapy treatment (for example, speech therapy)

2.1.5 Warranties

All hearing instruments and/or devices covered under the Hearing Industry Association of Canada (HIAC) agreement must carry, at a minimum, a two-year warranty and one-year 'loss and damage replacement' coverage for one occurrence per aid. NIHB clients must be entitled to the same warranties and provisions as all other clients. All items must have a 90-day return privilege at no cost to the client.

For other hearing devices (BAHS processor, CI processor and FM systems) the manufacturer's warranty and loss and damage replacement policy apply.

Follow-up

Aftercare services take place when the original fitting and dispensing fee no longer covers the service provided.

Aftercare services involve:

  • adjustment to the client's fitting, including earmold repairs or replacements
  • advice to the client outside a formal appointment, regarding their fitting or their hearing loss which is accommodated by the clinic and/or service provider

2.1.6 Repairs

Repairs are made to restore the hearing device to its original level of performance. A prescription is not needed for repairs; however a prior approval is required for all billable repairs.

Hearing device repairs done under warranty are not subject to service fees.

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • warranty is expired
  • except for hearing aids, a detailed description of all repairs performed with dates and costs must be kept on file for each client
  • in the case of hearing aids, repairs must be covered according to the established price

Warranty on repairs

All repairs for FM system, BAHS and CI processors must come with a minimum six-month warranty.

Repair for hearing aids warranty periods must be consistent with the HIAC agreement:

  • repairs carried out on a hearing aid during the product purchase warranty period are guaranteed for a maximum of 12 months after repair or until the original product warranty expires, whichever comes first
  • all repairs and remakes carried out on a hearing aid after the warranty period expires will be subject to a maximum cost outlined in the pricing grid and will carry a 12-month warranty if the hearing device is less than five (5) years old
  • charges for repairs and remakes can only be billed after the warranty period, 24 months for new aids and 12 months after the repair or remake of an aid
  • a remake includes the provision of a new shell for the aid and replacement of required existing electronic components to ensure that the aid has been returned to the equivalent operating standard of a new aid

Repair timeline

  • the provider should have at least one permanent business location with the capacity to repair hearing devices and to send devices to manufacturers for repair
  • batteries and repair services must be available at the point of service during regular business hours
  • a loaner hearing device should be provided free of charge if requested by the client when same-day repairs cannot be completed
    • a Behind The Ear (BTE)-type hearing aid is an acceptable loan for In The Ear (ITE) and In The Canal (ITC) hearing aids
  • the device should be returned to the client promptly

2.1.7 Replacement requirements

To be eligible for replacement the item must meet ONE of the following conditions:

  • be outside the recommended replacement guideline
  • the item no longer meets the client's needs due to a change in medical condition
  • not working and outside of warranty where the cost of repair exceeds the cost of a new item (except for items covered under an existing repair agreement)

All requests for replacement require a new prescription. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

For items eligible for a trade in allowance such as the cochlear implant processor, the trade-in value must be submitted with the prior approval.

2.1.8 Services included in the price

Following a maximum ninety (90) day trial, clients may request the following services to be provided at no additional charge:

  • appropriate reinforcement of information, instructions, and retraining on the device
  • any modifications to improve the comfort of the device
  • any modifications to the electroacoustic characteristics of the device based upon reactions and experiences of the client
  • any adjustments or changes to amplification levels due to client reactions to enhance client benefit from the device
  • other further adjustments

2.1.9 Terminology

Item code

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval

A program coverage confirmation is issued by a FNIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program.

Recommended replacement guidelines

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.

Maximum price

The NIHB program has established a maximum price for specific items. Maximum price information may be found on the price files located on the Express Script Canada website.

2.2 Hearing assessment

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400639 Complete hearing assessment MD, NP, AUD, HIP AUD, HIP No 1 every 5 years
99400642 Hearing reassessment MD, NP, AUD, HIP AUD, HIP Yes 1 every 2 years To be used for all clients over the age of 18 or any client under 18 that does not have a hearing aid or a CI processor
99401244 Hearing reassessment pediatric initial (first hearing aid or cochlear implant processor) MD, NP, AUD AUD Yes 6 in first 2 years ( 4 in year 1 and 2 in year 2)

Code to be used only when the client under 18 gets a hearing aid

There must be a minimum of 3 months between each reassessment.

After 2 years use code 99401245 as applicable

99401245 Hearing reassessment pediatric annual MD, NP, AUD AUD Yes 1 per year To be used after expiration of code 99401244 for clients under 18 years who have a hearing aid or a CI processor

2.3 Hearing devices

2.3.1 Hearing aids

Hearing aids criteria for children (under 18)

  • Clients are eligible for coverage if there is a hearing loss of 25 dB or greater at any frequency from 500 to 4000 Hz

Hearing aids criteria for adults

  • Clients are eligible for coverage if there is a minimum of 30 dB hearing loss at three frequencies from 500, 1000, 2000, 3000 and 4000 Hz
Item number Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99401255 Completely in canal or invisible in canal, left AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99401256 Completely in canal or invisible in canal, right AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400256 Hearing aid BiCROS AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400257 Hearing aid bone conduction, left AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400258 Hearing aid bone conduction, right AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400255 Hearing aid CROS AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400522 Hearing aid digital basic, left AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400523 Hearing aid digital basic, right AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400524 Hearing aid digital custom, left AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years
99400525 Hearing aid digital custom, right AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years

* NIHB recognizes Hearing Instrument Practitioners (HIP) as recommenders for audiometric tests and hearing equipment and supplies for adults 18 years of age or older. This applies in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance by a professional body overseeing the practice. This includes: Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia and Newfoundland.

2.3.2 Bone anchored hearing system (BAHS) processor

Audiologists prescribing or providing BAHS must work in a facility with dedicated BAHS program or have training with BAHS and experience with clients having BAHS.

Eligibility criteria (initial):

  • the client has conductive/mixed hearing loss that cannot be treated medically and for whom an air conduction hearing aid is contraindicated (decision should be made by an audiologist and ENT physician)
  • the prescriber has identified the client as one who would benefit from BAHS

Eligibility criteria (replacement):

  • the BAHS audio processor currently in use is either:
    • 5 years old or older (from the original fitting date)
    • not working (and is no longer under warranty) and the cost of repair exceeds the cost of a new processor

Softband

Eligibility criteria (initial and replacement):
  • the client is too young (generally under 5 years) for a BAHS implant
  • when recommended by an audiologist for clients that cannot have an implant
Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401229 Hearing aid processor bone anchored, left AUD, ENT AUD Yes 1 every 5 years
99401228 Hearing aid processor bone anchored, right AUD, ENT AUD Yes 1 every 5 years
99400947 Parts for bone anchored hearing system AUD AUD Yes
99401230 Softband AUD, ENT AUD Yes 1 per year Client cannot have an implant usually due to age (under 5)

2.3.3 Cochlear implant processor

Audiologists prescribing or providing CIs must work in a facility with dedicated CI program or have training with CIs and experience with clients having CIs.

Eligibility criteria (initial), children (under 18)

  • severe-to-profound sensorineural hearing loss bilaterally
  • receive little or no benefit from hearing aids
  • the prescriber has identified the client as one who would benefit from CI

Eligibility criteria (initial), adults:

  • moderate to severe/profound sensorineural hearing loss
  • limited benefit from optimally fitted amplification

Eligibility criteria (replacement), all ages:

  • the CI processor currently in use is either:
    • 5 years old or older (from the original fitting date)
    • not working (and is no longer under warranty) and the cost of repair exceeds the cost of a new processor
Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401227 Cochlear implant processor, left AUD, ENT AUD Yes 1 every 5 years
99401226 Cochlear implant processor, right AUD, ENT AUD Yes 1 every 5 years
99400948 Parts for cochlear implant processor AUD AUD Yes

2.3.4 FM system

To be eligible for an FM system the client must have ONE of the following:

  • client has a unilateral or bilateral permanent hearing loss
  • client has a need to improve functional auditory capacity that cannot be met with standard amplification
  • client has been diagnosed with auditory neuropathy
Item number Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99400955 FM system complete MD, NP, AUD, HIP AUD, HIP Yes 1 every 5 years Includes two receivers, audio shoes (right and left), a battery charger and a direct audio input cable
99400962 Fitting fee FM systems MD, NP, AUD, HIP AUD, HIP Yes 1 every 5 years
99400960 Accessories for FM system MD, NP, AUD, HIP AUD, HIP Yes 1 every 5 years
99400956 Audio shoe FM system, left MD, NP, AUD, HIP AUD, HIP Yes 1 every 5 years
99400957 Audio shoe FM system, right MD, NP, AUD, HIP AUD HIP Yes 1 every 5 years

* NIHB recognizes Hearing Instrument Practitioners (HIP) as recommenders for audiometric tests and hearing equipment and supplies for adults 18 years of age or older. This applies in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance by a professional body overseeing the practice. This includes: Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia and Newfoundland.

2.3.5 Non-implantable bone conduction hearing system

For the non-implantable bone conduction hearing systems, the coverage will be provided when ONE of the following criterion is met:

  • the client has a bilateral or unilateral conductive hearing loss that cannot be addressed by conventional hearing aids. The client must have excellent bone conduction thresholds (5 to -5 dB) in the aided ear(s)
    • Examples include atresia or recurrent otitis media with effusion

    OR

  • the client has a single-sided sensorineural hearing loss and a trial with a CROS hearing aid was attempted with no success

    OR

  • the client is a candidate for surgical implantation who has not met the age requirement, a candidate for whom surgery is contra-indicated, or a candidate who is unwilling to undergo surgery
Item number Item name Prescriber* Provider Prior approval required Recommended replacement guidelines Additional details
99401273 Adhesive adapter, left AUD, MD, NP, HIP AUD, HIP Yes 5 boxes per year The box contains 15 adhesive adapters
99401274 Adhesive adapter, right AUD, MD, NP, HIP AUD, HIP Yes 5 boxes per year The box contains 15 adhesive adapters
99401276 Cable, bone conduction hearing system AUD, MD, NP, HIP AUD, HIP Yes 1 every 2 years
99401271 Non-implantable bone conduction hearing system, left AUD, MD, NP, HIP AUD, HIP Yes 1 every 5 years Each processor unit comes with an accessory box that includes:
  • 1 positioning tool
  • 1 retention cup
  • 1 cleaning brush
  • 3 colour sleeves
  • 1 pack of batteries (6)
  • 1 daily storage case
  • 1 sheet design stickers
  • 1 headband
99401272 Non-implantable bone conduction hearing system, right AUD, MD, NP, HIP AUD, HIP Yes 1 every 5 years Each processor unit comes with an accessory box that includes:
  • 1 positioning tool
  • 1 retention cup
  • 1 cleaning brush
  • 3 colour sleeves
  • 1 pack of batteries (6)
  • 1 daily storage case
  • 1 sheet design stickers
  • 1 headband
99401275 Sound check tool, bone conduction hearing system AUD, MD, NP, HIP AUD, HIP Yes 1 every 5 years

* NIHB recognizes Hearing Instrument Practitioners (HIP) as recommenders for audiometric tests and hearing equipment and supplies for adults 18 years of age or older. This applies in provinces and territories where these activities are deemed within their scope of practice, and in accordance with appropriate legislation, regulations, acts or formal governance by a professional body overseeing the practice. This includes: Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia and Newfoundland.

2.4 Batteries and parts

2.4.1 Batteries

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400259 Batteries hearing aid, left GEN, AUD, HIP No 24 every 144 days
99400643 Batteries hearing aid, right GEN, AUD, HIP No 24 every 144 days
99401316 Batteries, non-implantable bone conduction, left GEN, AUD, HIP Yes 32 every 90 days
99401317 Batteries, non-implantable bone conduction, right GEN, AUD, HIP Yes 32 every 90 days
99400970 Disposable battery BAHS processor, left GEN, AUD, HIP No 3 per week
99400971 Disposable battery BAHS processor, right GEN, AUD, HIP No 3 per week
99400968 Disposable battery cochlear implant, left GEN, AUD, HIP No 7 per week
99400969 Disposable battery cochlear implant, right GEN, AUD, HIP No 7 per week
99401252 Rechargeable battery charger CI processor GEN, AUD, HIP No 1 every 5 years
99401249 Rechargeable battery charger hearing aid GEN, AUD, HIP No 1 every 5 years
99401251 Rechargeable battery CI processor, left   GEN, AUD, HIP No 1 per year
99401250 Rechargeable battery CI processor, right   GEN, AUD, HIP No 1 per year
99401248 Rechargeable battery hearing aid, left   GEN, AUD, HIP No 1 every 3 years
99401247 Rechargeable battery hearing aid, right   GEN, AUD, HIP No 1 every 3 years

2.4.2 Parts

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400276 Accessories for hearing aids AUD, HIP AUD, HIP No 1 every 5 years
99400266 Ear mold new, left AUD, HIP AUD, HIP Yes 1 every 5 years
99400267 Ear mold new, right AUD, HIP AUD, HIP Yes 1 every 5 years
99400245 Replacement ear mold & impression, adult, left AUD, HIP No 1 every 2 years
99400246 Replacement ear mold & impression, adult, right AUD, HIP No 1 every 2 years
99400268 Replacement ear mold & impression, child, left AUD, HIP No 4 per year
99400269 Replacement ear mold & impression, child, right AUD, HIP No 4 per year
99400866 Tubes/domes over the ear, left AUD, HIP AUD, HIP No 1 pack of 4 per year
99400900 Tubes/domes over the ear, right AUD, HIP AUD, HIP No 1 pack of 4 per year

2.5 Servicing

2.5.1 Fees

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401225 Fitting and dispensing fee, left AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years Service code for fitting and dispensing hearing aid which is performed by the provider while the hearing aid is still under the manufacturer's warranty (for example, adjusting the hearing aid and counseling the client)
99401224 Fitting and dispensing fee, right AUD, HIP, MD, NP AUD, HIP Yes 1 every 5 years Service code for fitting and dispensing hearing aid which is performed by the provider while the hearing aid is still under the manufacturer's warranty (for example, adjusting the hearing aid and counseling the client)
99400640 Hearing aid performance check and readjustment fee, left AUD, HIP AUD, HIP Yes 1 per year Service code for checking and adjusting the hearing device no longer under the original manufacturer's warranty. Includes evaluating the performance of the device (for example, electroacoustic evaluation, Real Ear Measures (REM), listening check, client interview) and making necessary adjustments to the device through programming, earmold modification, etc. Must be client initiated
99400641 Hearing aid performance check and readjustment fee, right AUD, HIP AUD, HIP Yes 1 per year Service code for checking and adjusting the hearing device no longer under the original manufacturer's warranty. Includes evaluating the performance of the device (for example, electroacoustic evaluation, Real Ear Measures (REM), listening check, client interview) and making necessary adjustments to the device through programming, earmold modification, etc. Must be client initiated
99400274 In office service fee, left AUD, HIP No Service code for minor repairs to hearing aids in the office (for example, replacing the tubing on Behind The Ear (BTE) earmolds, replacing worn or malfunctioning parts, etc.) Includes supply if necessary.
99400275 In office service fee, right AUD, HIP No Service code for minor repairs to hearing aids in the office (for example, replacing the tubing on Behind The Ear (BTE) earmolds, replacing worn or malfunctioning parts, etc.) Includes supply if necessary.
99400272 Repairs out of office dispenser service fee, left AUD, HIP Yes Service code for any work/service carried out by the provider when the hearing device is sent to the manufacturer for repair.
99400273 Repairs out of office dispenser service fee, right AUD, HIP Yes Service code for any work/service carried out by the provider when the hearing device is sent to the manufacturer for repair.
99400264 Return fee hearing aid, left AUD, HIP Yes
99400265 Return fee hearing aid, right AUD, HIP Yes

2.5.2 Repairs and remake

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401122 Remake by manufacturer, left AUD, HIP Yes Outside warranty period
99401123 Remake by manufacturer, right AUD, HIP Yes Outside warranty period
99400966 Repair, BAHS processor, left AUD Yes
99400967 Repair, BAHS processor, right AUD Yes
99400964 Repair, cochlear implant processor, left AUD Yes
99400965 Repair, cochlear implant processor, right AUD Yes
99400963 Repair, FM systems AUD Yes
99400270 Repair, hearing aid manufacturer, left AUD, HIP Yes Outside warranty period
99400271 Repair, hearing aid manufacturer, right AUD, HIP Yes Outside warranty period
99401277 Repair, non-implantable bone conduction hearing system, left Yes
99401278 Repair, non-implantable bone conduction hearing system, right Yes

2.5.3 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400961 Delivery, FM system AUD, HIP Yes 1 per client order
99401096 Delivery, hearing aid charge from manufacturer AUD, HIP No 1 per client order
99401260 Delivery, audiology AUD, HIP Yes Delivery of equipment to the client
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