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In an effort to help our members receive appropriate, safe, and affordable
care for obstructive sleep apnea (OSA) and other sleep disorders, Independence
has partnered with AIM Specialty Health® (AIM), an independent
company. The goal is to streamline the precertification process for sleep
studies, APAP, BPAP, and CPAP (PAP) machines and supplies (e.g., tubing, water
chambers, masks) and enhance member compliance with prescribed usage.
Precertification requirements
As of January 1, 2015, in addition to obtaining precertification for PAP
machines, durable medical equipment (DME) providers are also required to obtain
precertification for all related supplies. This requirement applies to all new
and existing patients on PAP therapy.
Currently, ordering providers request precertification of sleep studies and
CPAP titration studies in the facility setting through AIM. Beginning on
February 16, 2015, DME providers will be required to submit
precertification requests for PAP machines and all related supplies (e.g.,
tubing, water chambers, masks) through AIM.
We are making enhancements to the NaviNet® web portal to
accommodate the submission of precertification requests through the AIM
Provider PortalSM using the AIM transaction. Once implemented,
providers must obtain precertification through AIM.
Note: Until the enhancements are completed, providers should continue
to submit precertification requests for PAP machines and supplies using the
Authorizations transaction in NaviNet. We will post a notification on NaviNet
Plan Central once the AIM Provider PortalSM is updated.
Compliance monitoring requirements
To ensure that our members are using their PAP machines as prescribed by the
ordering provider, AIM incorporates a compliance element to their
precertification process, which will begin on February 16, 2015. Usage data
will be collected for all members using PAP therapy. This data will be analyzed
by AIM to determine if the member has been compliant in using their PAP machine
and if a request for precertification of continued rental and/or supplies will
be approved or denied.
For members who are new to PAP therapy, DME providers must contact AIM to
request approval for the initial PAP set-up, prior to dispensing equipment and
supplies. For those members currently on PAP therapy,
the DME provider must also contact AIM to request approval for on-going
treatment. DME providers will need to submit the date upon which the member
initiated PAP therapy on the current device ? regardless of payer.
The AIM system will then calculate where the member is in the rental cycle, if
applicable.
Please note the following when requesting precertification through AIM:
- Rentals. During the rental period, the precertification will cover
the PAP machine, humidifier, and all supplies. The precertification will be
good for 90 days.
- Owned. Once the rental period ends, the precertification will only
cover supplies (A-codes). The precertification will be good for one year.
If AIM denies a precertification request after analyzing the compliance data, a
denial letter will be mailed to the DME provider, the ordering provider, and
the member. This notification encourages the ordering provider to contact the
member and determine the appropriate next steps.
Guidelines
Independence will adopt and follow AIM's Clinical Guidelines, which are
available on
AIM's website,
when reviewing precertification requests for our commercial members. AIM will
follow the established Medicare coverage guidance when reviewing requests for
our Medicare Advantage HMO and PPO members. Policy Notifications for the
following policies, which address sleep disorder testing, are available on our
Medical Policy
portal. Included within the policies are links to the guidelines that AIM
will use to determine usage compliance and medical necessity for PAP machines
and supplies, a complete list of codes that require precertification, and
quantity limits set for the supplies.
- Commercial: #07.03.05r: Sleep Disorder Testing and Positive Airway
Pressure Therapy
- Medicare Advantage: #MA07.058a: Sleep Disorder Testing and Positive
Airway Pressure Therapy
Please call
1-800-ASK-BLUE (
1-800-275-2583) if you have any
questions.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
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