Effective for dates of service on or after September 1, 2013,
precertification is required for commercial members for sleep studies and
continuous positive airway pressure (CPAP) titration in the facility
setting (i.e., free standing sleep study center or hospital sleep study
lab). This change will also be implemented for Medicare Advantage HMO members
effective January 1, 2014.
AmeriHealth has delegated the responsibility for precertification of sleep
studies and CPAP titration studies in the facility setting to AIM Specialty
Health[
SM] (AIM). AIM uses their Sleep Disorder Management
Diagnostic & Treatment Guidelines, adopted by AmeriHealth and available on
their website at
www.aimspecialtyhealth.com, to
guide the utilization of these services for our members. The guidelines involve
integration of medical information from multiple sources to support the use of
high-quality advanced sleep management services. The process for criteria
development is based on technology assessment and peer-reviewed medical
literature, including clinical outcomes research and consensus opinion in
medical practice. It takes into consideration recommendations from:
American Academy of Sleep Medicine (AASM)
American Thoracic Society (ATS)
Agency for Healthcare Research and Quality (AHRQ)
Centers for Medicare & Medicaid Services (CMS)
AmeriHealth covers sleep studies and CPAP titration conducted in the home and
facility setting based on medical necessity criteria outlined in our Medical
Policy #07.03.05o: Sleep Disorder Testing.
Precertification is not required
for sleep studies that are conducted in the home setting. CPAP titration in
the home setting continues to require precertification through AmeriHealth
based on the standard rules for rental of durable medical equipment.
Members should obtain sleep studies and CPAP titration in the setting that is
most appropriate for their condition, based on factors such as:
the setting that has been determined to be both cost-effective and safe for the
member;
the level of care required by the member based on his or her medical history
and current health status;
current standards in medical practice.
Member cost-sharing (deductible, coinsurance, and/or copayments) applies in
accordance with the terms of the member?s benefit contract.
Obtaining precertification for sleep studies in the
facility setting
Providers who request coverage for administration of a sleep study in a
facility setting are required to provide details about the member's medical
history to support the request.
All precertification requests for sleep studies and CPAP titration in a
facility setting should be submitted through the AIM
ProviderPortal
SM, which can be accessed through the
NaviNet
® web portal by selecting
Authorizations from the
Plan Transactions menu, then
AIM.
It is very important that providers use NaviNet to verify member-specific
requirements or refer to the most current
precertification requirement
lists on our website. Failure to obtain precertification for any of the
services that require it may result in a reduction in payment or nonpayment for
the services not precertified. If you have any questions about these changes to
place of service options for sleep studies, please call Customer Service at
1-800-275-258 for providers in Pennsylvania and
Delaware or at
1-888-YOUR-AH1 (
1-888-968-7241) for providers in New Jersey.
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