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As previously communicated, effective for dates of service on or
after January 1, 2014, precertification is required
for Medicare Advantage HMO and PPO members for sleep studies and continuous
positive airway pressure (CPAP)
titration in the facility setting (free standing sleep study center or hospital
sleep study lab). Note: This change was
implemented for commercial members on September 1, 2013.
IBC has delegated the responsibility for precertification of sleep studies
and CPAP titration studies in the facility setting
to AIM Specialty HealthSM (AIM), an independent company. AIM uses
their Sleep Disorder Management Diagnostic &
Treatment Guidelines, adopted by IBC 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 and state-of-the-art 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)
IBC covers sleep studies conducted in the home setting, without
precertification, when the medical necessity
criteria outlined in Medical Policy #07.03.05o: Sleep Disorder Testing are met
(#07.03.05p as of January 1, 2014).
Precertification is not required for sleep studies that are conducted
in the home setting. However, CPAP titration
in the home setting continues to require precertification through IBC 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 the 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
ProviderPortalSM, 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 list 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-ASK-BLUE.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
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