As a reminder, as part of our effort to ensure that our members receive appropriate, safe, and affordable care that is consistent with best practices, AmeriHealth has partnered with AIM Specialty Health^® (AIM) to expand its sleep testing program to include home-based sleep testing. As of March 1, 2018, home-based sleep testing will require precertification for all AmeriHealth members.

Guidelines

AmeriHealth follows AIM?s Sleep Disorder Management Diagnostic and Treatment Guidelines. AIM uses their 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 and peer-reviewed medical literature including clinical outcomes research.

Submitting requests through AIM

All precertification requests for facility-based sleep testing or home-based sleep testing should be submitted using AIM's ProviderPortal^SM. Providers can access AIM's ProviderPortal directly through AIM's website or through the NaviNet^® web portal by selecting Authorizations from the AmeriHealth Workflows menu, then AIM. Providers who request coverage for home-based sleep testing are required to provide details about the member?s medical history to support the request.

It is important for providers to use NaviNet to verify member eligibility and benefits, and to refer to the most current precertification requirement lists for AmeriHealth New Jersey and AmeriHealth Pennsylvania. Failure to obtain precertification for any of the services that require precertification may result in a reduction in payment or nonpayment for services provided.

Medical Policy

For more information about sleep testing services that require precertification, please refer to AmeriHealth Medical Policy #07.03.05u: Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies.

Included within the medical policy are links to the Sleep Disorder Management Diagnostic and Treatment Guidelines that AIM uses during the precertification process to determine medical necessity for facility- and home-based sleep testing. In addition, the medical policy includes an updated list of codes that require precertification.

To view this medical policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select the Commercial tab, and then type the policy name or number into the Search field.

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