As part of our effort to ensure that our members receive appropriate, safe, and affordable care that is consistent with recognized best practices, Independence has partnered with AIM Specialty Health® (AIM), an independent company, 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 Independence members.
Guidelines
For commercial members: Independence will adopt and follow AIM's Sleep Disorder Management Diagnostic and Treatment Guidelines when reviewing precertification requests for all Independence 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.
For Medicare Advantage members: AIM will follow the established Medicare coverage guidance when reviewing requests for Independence Medicare Advantage members. AIM utilizes Medicare coverage guidance (e.g., Local Coverage Determinations, National Coverage Determinations). If no Medicare coverage guidance exists, AIM will follow their Sleep Disorder Management Diagnostic and Treatment Guidelines.
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 on the Independence website. Failure to obtain required precertification for services may result in a reduction in payment or nonpayment for the services provided but not precertified.
Policies
For more information about home-based sleep testing services that require precertification, please refer to the following Independence policies, which are currently posted as Notifications and will go into effect March 1, 2018:
- Commercial: #07.03.05u: Sleep Disorder Testing and Positive Airway Pressure Therapy
- Medicare Advantage: #MA07.058f: Sleep Disorder Testing and Positive Airway Pressure Therapy
Included within the policies 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 policies include a complete list of codes that will require precertification.
To view the Notifications for these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under Active Notifications.
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