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, Independence has partnered with AIM Specialty Health® (AIM), an independent company, to expand its sleep testing program to include home-based sleep testing. As of March 1, 2018, home-based sleep testing requires precertification for all Independence members.
Guidelines
For commercial members: Independence 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 Independence 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.
For Medicare Advantage members: AIM uses the applicable Medicare coverage guidelines when reviewing requests for Independence Medicare Advantage members (e.g., Local Coverage Determinations, National Coverage Determinations). If no Medicare coverage guidelines exist, AIM follows AIM?s Sleep Disorder Management Diagnostic and Treatment Guidelines.
Submitting requests through AIM
All precertification requests for facility-based sleep testing or home-based sleep testing 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 Independence 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 on our website. Failure to obtain precertification for services that require precertification may result in a reduction in payment or nonpayment for the services provided.
Policies
For more information about sleep testing services that require precertification, please refer to the following Independence policies:
- Commercial: #07.03.05u: Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
- Medicare Advantage: #MA07.058f: Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
Included within the policies 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 policies include an updated list of codes that require precertification.
To view these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select the Commercial or Medicare Advantage tab, and then type the policy name or number in the Search field.
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