NC Medicaid uses DMA-0001 to request prior approval for hearing aids and related items, including ear molds, accessories, FM systems and repairs or replacements. Audiologists and otolaryngologists meet it when fitting a new aid or replacing or repairing one for a Medicaid beneficiary. The request lists each aid by manufacturer, model, type, style and invoice cost and describes the medical necessity.
The audiologist's or otolaryngologist's office completes recipient, diagnosis, provider and hearing aid information, describes medical necessity and signs as requesting provider. The beneficiary completes nothing.
Download the current version from the source each time; forms change without notice.
Hearing Aid Services Request for Prior Approval
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The form lists four: medical clearance, an audiogram, a written evaluation and warranty information. Put them behind the form when faxing, or upload them to the prior approval request in NCTracks, which is the preferred submission route.
Yes. Item 19 offers new, replacement or repair, and the right and left aid sections ask for manufacturer, model, type, style, warranty status and invoice cost. Ear molds, accessories and FM system repairs are requested on the same form.