As part of our effort to ensure that our members receive appropriate, safe, and affordable care that is consistent with recognized best practices, AmeriHealth has partnered with AIM Specialty Health® (AIM) to expand its sleep testing program to include home-based sleep testing. Effective for dates of service on or after March 1, 2018, home-based sleep testing will require precertification for all AmeriHealth members.
Guidelines
AmeriHealth will adopt and follow AIM's Sleep Disorder Management Diagnostic and Treatment Guidelines when reviewing precertification requests for all AmeriHealth commercial members. AIM's medical necessity guidelines are consistent with the clinical appropriateness criteria based on technology assessment, peer-reviewed medical literature including clinical outcomes research, and consensus opinion in medical practice.
Submitting requests through AIM
All precertification requests for sleep testing in a facility or home-based setting should be submitted using AIM's ProviderPortalSM. Providers can access AIM's ProviderPortal directly through AIM's website or through the NaviNet® web portal by selecting Authorizations from the Workflows menu, then AIM. Providers who request coverage for home-based sleep testing will be required to provide details about the member?s medical history to support the request.
It is very important for providers to use NaviNet to verify member eligibility and benefits and refer to the most current precertification requirement lists for AmeriHealth New Jersey and AmeriHealth Pennsylvania. Failure to obtain required precertification for services may result in a reduction in payment or nonpayment for the services provided but not precertified.
Medical Policy
For more information about home-based sleep testing services that require precertification, please refer to AmeriHealth Medical Policy #07.03.05u: Sleep Disorder Testing and Positive Airway Pressure Therapy, which is currently posted as a Notification and will go into effect March 1, 2018.
Included within the medical policy are links to the Sleep Disorder Management Diagnostic and Treatment Guidelines that AIM will use during the precertification process to determine usage compliance and medical necessity for home-based sleep testing. In addition, the medical policy includes a complete list of codes that will require precertification.
To view the Notification for this medical policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial under Active Notifications.
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