Free 51930.FH11 - Indiana

REQUEST FOR AUTHORIZATION FOR AUDIOLOGY SERVICES
State Form 51930 (R2 / 1-07) / BCD 0200 Indiana Family and Social Services Administration Early Intervention Services / Childrens Special Health Care Services Name of child ICD-9 Estimated length of request Name of provider County Agency Date of birth (month, day, year)

30 days

60 days

Duration of IFSP

Other

Place a check mark beside each service you are requesting.
Service

CPT Code Description
Individual treatment of auditory processing disorder (aural rehabilitation) (1 unit = 4 visits)* Hearing Aid management (Lifetime maximum = 4 units)* Pure tone audiometry (threshold); air only Pure tone audiometry (threshold); air & bone SRT or SDT: Speech Audiometry Threshold Comprehensive audiometry threshold evaluation and speech recognition/discrimination (92553 and 92556 combined) Tympanometry (impedance testing) Acoustic Reflex Testing Visual Reinforcement Audiometry Conditioning Play Audiometry Select Picture Audiometry ABR: Audiometry evoked potential for evoked response audiometry and/or testing of the central nervous system (brainstem evoked response) Automated ABR: Automated Audiometry evoked potential for evoked response audiometry and/or testing of the central nervous system (brainstem evoked response) OAE - limited: Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) OAE - complete: comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies) Hearing Aid Evaluation/examination and selection; monaural Hearing Aid Evaluation/examination and selection; binaural IFSP Team meeting (on-site) IFSP Team meeting (off-site) Direct Child Treatment (on-site)* Direct Child Treatment (off-site)* Family Counseling and Training - Onsite (15 minutes)* (review results, recommendations, and counseling) Family Counseling and Training - Offsite (15 minutes)* Hearing Aid - monaural behind the ear (BTE)* Hearing Aid - binaural behind the ear (BTE)* Dispensing Fee monaural Dispensing Fee Binaural Hearing aid, digital, monaural Hearing aid, digital, biaural Hearing service miscellaneous (Earmold 1 or 2)* (Maximum = 4 per year per ear) Hearing aid supplies - batteries (4 pack - limit 10 packs per year)* Hearing aid supplies - Pediatric hearing aid kit*

CPT
92507 92552 92553 92555 92557 92567 92568 92579 92582 92583 92585 92586 92587 92588 92590 92591 X1015 X1016 X1021 X1022 X1031 X1032 V5060 V5140 V5090 V5110 V5257 V5261 V5264 V5266 V5267

Maximum Rate
95.40 11.47 17.60 9.91 31.44 14.09 9.91 18.90 19.16 23.60 104.06 49.41 40.52 56.47 38.89 45.56 15.37 20.05 14.45 18.85 14.45 18.85 $900 per ear $1800 both ears $180 $270 $900 per ear $1800 both ears $35 per ear $5 $15

* Service or equipment must be written into the childs IFSP and signed by the parent(s) and primary care physician prior to authorization. Please note that services (including evaluation and assessment activities) may not be provided without the authorization of the Service Coordinator. Audiological services or equipment not listed on the form require prior approval from the Bureau of Child Development prior to authorization.
Signature of audiologist Signature of Service Coordinator Date (month, day, year) Date (month, day, year) Telephone number Fax number Fax number

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Telephone number

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