Tuesday, September 20, 2022

Blue Cross Blue Shield Sleep Study Authorization

An Important Reminder From Anthem About Home Sleep Testing With Novasom

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Aug 17, 2018Products & Programs

Last year, Anthem Blue Cross and Blue Shield shared information about the authorization process for home sleep testing. Once again, we are including a reminder about the process in this edition of the Network Update. The authorization process for home sleep testing with NovaSom is designed to be simple for ordering physicians. NovaSom is a network participating provider of home sleep testing equipment and interpretation.

Anthem delegates the management of sleep testing and treatment services to AIM Specialty Health® on our behalf. To request an authorization for HST with NovaSom, just contact AIM toll free at 1-866-789-0158 or via Availity .

If your authorization request is approved, an order is automatically sent to NovaSom for you. There is no need to contact or fax an order form to NovaSom on your patients behalf.

Home sleep testing with NovaSom

Anthem members suspected of having noncomplicated obstructive sleep apnea have the ability to test at home using NovaSoms AccuSom® wireless HST device. AccuSom wireless sleep studies are performed in the patients home and self-administered, which may be more comfortable and reflective of typical sleep behaviors than those provided in a lab.

Accessing AIM via Availity

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An Important Reminder About Authorization Requests For Aim Programs

As a reminder, AIM processes prior authorization requests on behalf of Blue Cross and Blue Shield of North Carolina for all Diagnostic Imaging Management, Sleep Study, and Medical Oncology programs. Authorization requests with an incorrect site may result in the claim processing being delayed or denied.

To avoid this issue, please be sure your requests contain the correct service site:

  • To make sure you select the correct service site, search using the site’s billing National Provider Identifier rather than the name of their location.
  • If you dont have this information, simply contact the facility and ask for their billing NPI.

Thank you for following these guidelines to ensure authorizations are processed correctly and in a timely manner.

Youll Receive A Notice

Florida Blue will mail you a letter confirming that your medical service have been approved or denied. Keep the letter for future reference. If the request has not been approved, the letter will tell you the steps to appeal the decision. We’ll also let your doctor know the decision, so please contact them to discuss other medical service options.

You can check the status of the request by calling the number on the back of your member ID card.

We are here to help you! If you have any questions or need further assistance after reading these steps, please call us at the number on the back of your member ID card. If your provider has any questions, they should call us at 1-800-727-2227.

Please note: Services, procedures or medications that may not require prior approval may be subject to medial review and medical coverage guidelines. If you have a BlueCare health plan, other services that require your participating provider to obtain an approval can include: behavioral health services, hospitalization, rehabilitation services, home care, select DME and cardiac nuclear medicine studies, etc. Please refer to your contract or benefit booklet or call us at the number on the back of your member ID card for more details.

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Mental Health Prior Authorization

A few plans may continue to require prior authorization for mental health services. Contact Companion Benefits Alternatives to verify by calling 800-868-1032. CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan.

BlueChoice® HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.

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BCBS of Massachusetts Medical Policy

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This website is operated by Horizon Blue Cross Blue Shield of New Jersey and is not New Jerseys Health Insurance Marketplace. This website does not display all Qualified Health Plans available through Get Covered NJ. To see all available Qualified Health Plan options, go to the New Jersey Health Insurance Marketplace at Get Covered NJ.

Products and services are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon Healthcare of New Jersey, Braven Health, and/or Horizon Healthcare Dental, Inc., each an independent licensee of the Blue Cross Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® name and symbols are registered marks of the Blue Cross Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. The Braven Health name and symbols are service marks of Braven Health.

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Services That Need Approval

Depending on what type of plan you have, we may need to review and approve some of your health care services before we cover them. We call this prior authorization.

If you need preapproval, your doctor or health care professional will request a review on your behalf. Once we get the request, we’ll begin the review process. So, it’s important they send us all the materials we need for your review, up front.

If you’re looking for more information about prescription drug prior authorization, read Why do I need prior authorization for a prescription drug?

There are four types of review for health care services:

  • Preservice non-urgent review: When you need to get a certain health care service, but it isn’t urgent. It can take up to 15 days for us to make our decision. This is the most common type of review.
  • Preservice urgent review: When you need to get a certain health care service as soon as possible, but it isn’t an emergency. It can take up to three days for us to make our decision.
  • Urgent concurrent review: When you’re already getting care and you can’t wait to get approval for it. This often happens with trips to the emergency room. It can take up to 24 hours for us to make our decision.
  • Postservice review: When you’ve already gotten the care you need and you request approval for it. It can take up to 30 days for us to make a decision.

If you disagree with our decision, you can appeal.

Here are some services that need approval. This is not a full list.

Fully Insured* Administrative Services Only Plans

The procedures or services on the below lists may require prior authorization or prenotification by BCBSTX Medical Management, AIM Specialty Health® or Magellan Healthcare®. These lists

  • Are not exhaustive
  • May not necessarily be covered under the member benefits contract
  • May periodically be updated to comply with American Medical Association and Centers for Medicare & Medicaid Services guidelines including procedure code updates.

Providers should check eligibility and benefits through Availity® or your preferred vendor, check the member/participant benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

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Sleep Disorder Management Program

Horizon BCBSNJ is working with AIM Specialty Health® , a specialty benefits management company, to offer a Sleep Disorder Management Program to certain self-insured employer group health plans administered by Horizon BCBSNJ that engages health care professionals in the management of the complexities associated with sleep disorders.

The AIM Sleep Disorder Management Program is designed to help members make more informed decisions regarding their care for sleep testing and therapy. We are committed to administering a comprehensive solution for sleep disorder management, designed to:

  • Improve the clinical appropriateness of sleep therapy testing and services
  • Help members find the highest value place of service for testing and therapy
  • Monitor and manage patient compliance of sleep therapy

Prospective Clinical Case Review

AIM performs prospective clinical appropriateness case review Prior Authorization & Medical Necessity Determination for sleep testing and therapy for Horizon BCBSNJ members. The following services are included in the program:

  • Home sleep test
  • Initial treatment order
  • In-lab sleep study
  • Ongoing treatment order
  • Oral appliances
  • Titration study

This program pertains to both new and existing sleep therapy patients.

Providers should contact AIM to obtain an order number before scheduling or performing any elective outpatient home-based diagnostic study or a facility-based diagnostic or titration study as well as for sleep treatment equipment and related supplies.

How To Determine If Prior Authorization Is Required

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You can verify coverage or benefits or determine pre-admission or prior authorization request requirements for a Member by going to Availity.com.

If you know the procedure codes, you can also check the following lists:

Prior Authorization Always Required

This list of procedure codes alwaysrequires prior authorization.

Subject to Medical Policies

This list of procedure codesis subject to BCBSWY medical policies and will deny for the following reasons if medical policy criteria is not met and an authorization is not on file: deny for no authorization, deny for not medically necessary, deny experimental/investigational, or deny for records.

BCBSWY recommends authorizing procedure codes associated with BCBSWY medical policies if the medical policy criteria is not met.

The following CPT codes are subject to medical policy and may deny for the following reasons if medical policy criteria is not met and an authorization is not on file:a.) deny for no authorizationb.) deny for not medically necessaryc.) deny experimental/investigationald.) deny for records

Please be aware that because of group specific requirements and payment logic, claims may deny for lack of authorization for CPT codes not listed in these tables. Providers can submit a retro-authorization when this occurs.

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Changes To Home Sleep Study Prior Approval Requirements For Fep Members

In January 2017, benefit prior approval requirements for sleep studies performed outside the home were implemented for some Federal Employee Program® members. Claims and appeals revealed that when outpatient facilities submitted claims for the equipment used for home-based sleep studies, our claims system presumed the services took place outside the home. For home-based sleep studies, this issue resulted in higher copayments and claim denials for FEP Basic Option members.

FEP made changes to correct this issue. Effective Sept. 4, 2018, the following unattended sleep study and portable test monitor procedure codes, when billed by outpatient facilities, are considered eligible home-based sleep studies that no longer require benefit prior approval:

  • 95800
  • G0400

Benefit prior approval continues to be required for all sleep studies performed outside the home.

As a reminder, it is important to check eligibility and benefits for all members. This step will help you verify membership and other important details, such as copayment, coinsurance, deductible amounts and whether benefit prior approval may be required for a member/service. We encourage you to check eligibility and benefits online using the Availity® Provider Portal, or your preferred web vendor. If you do not have web access, you may call 800-972-8382 to check eligibility and benefits for FEP members.

Update: Sleep Studies/testing Sleep Therapy Services And Equipment Advanced Imaging And Echocardiography Pre

Posted January 3, 2017

Benefit preauthorization and medical necessity reviews for the services listed below will not be required beginning April 3, 2017, as previously stated. Please check back here for future News and Updates as well as the Blue Review for additional information.

At Blue Cross and Blue Shield of Illinois , we use benefit preauthorization requirements to help make sure that the service or drug being requested is medically necessary, as defined in the members certificate of coverage. Benefit preauthorization is one of the many things we are doing to help make the health care system work better, by focusing on improving health care delivery.

Effective April 3, 2017, benefit preauthorization will be required prior to ordering diagnostic studies for obstructive sleep apnea and home and in-lab sleep testing for most BCBSIL PPO members. These benefit preauthorization requests must be submitted via the AIM Specialty Health® ProviderPortalSM, or by calling the AIM contact center at 866-455-8415. If benefit preauthorization is not obtained, as required, claims may be denied.

Additionally, effective April 3, 2017, providers are strongly advised to obtain medical necessity review through AIM prior to ordering services/equipment related to sleep therapy-related services and equipment, such as Positive Airway Pressure sleep therapy, Durable Medical Equipment and supplies associated with sleep therapy, and oral appliances.

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Sleep Studies To Require Preauthorization

Date:

Diagnostic sleep studies will require preauthorization for all dates of service on or after

We want to ensure that our BlueCross BlueShield of Western New York Commercial and Medicare Advantage patients receive sleep studies in the location that provides the greatest value and that is tailored to pre-existing medical conditions they may have. Services that will require preauthorization include:

  • Home sleep test and associated equipment
  • In-lab sleep study

Codes that will require preauthorization are:

  • 95782-3
  • 95810-11
  • G0398-400

Services performed in conjunction with emergency room services, inpatient hospitalization, and urgent care facilities are excluded.

Please follow our standard preauthorization request process for all diagnostic sleep studies performed on or after September 1, 2019.

  • Download, complete and fax the Preauthorization Form: Outpatient Services here
  • Log in and visit our Code and Comment tool to search codes and get direction on corresponding medical protocols

If you have any questions, please contact your BlueCross BlueShield account representative.

New Genetic Testing And Revised Sleep Study Preauthorization Requirements For H

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Update 7/31/2019: There has been a delay in transitioning preauthorization requirements for your Blue Cross and Blue Shield of Texas patients who are H-E-B partners and have the Blue Choice PPO health plan. The previous effective date of Aug. 1, 2019, for requesting preauthorization from BCBSTX to eviCore healthcare , an independent specialty medical benefits management company, has been delayed until

Correction 7/10/2019: The H-E-B Members Only Additional Preauthorization Procedure Code List Effective 8/1/2019 was updated to indicate genetic testing code 81212 will require preauthorization through eviCore. Procedure code 81213 previously required preauthorization through BCBSTX and will no longer require any preauthorization.

There are important changes to the preauthorization requirements for your Blue Cross and Blue Shield of Texas patients who are H-E-B partners and have the Blue Choice PPO health plan.

Effective , you will need to obtain preauthorization for an expanded list of molecular and genetic lab procedures through eviCore healthcare an independent specialty medical benefits management company. Also, procedure codes 81211, 81213, 81214, and 95805 that previously required preauthorization through BCBSTX for genetic testing or sleep studies have been removed.

Once you have determined your service requires preauthorization through eviCore, use one of the following methods to obtain authorizations:

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Prior Authorization Services List

The following is a list of Services that may require prior authorization for fully insured or ASO members as of 01/01/2022:

AIM Specialty Health is an operating subsidiary of Anthem and an independent medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to Blue Cross and Blue Shield of Texas.

BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or AIM. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor directly.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the members eligibility and the terms of the members certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the members ID card.

Prior Authorization Service Request

A Prior Authorization Service Request is the process of notifying BCBSWY of information about a medical service to establish medical appropriateness and necessity of services.

Members of some health plans may have terms of coverage or benefits that differ from the information presented here. The following information describes the general policies of Blue Cross Blue Shield of Wyoming and is provided for reference only. This information is NOT to be relied upon as pre-admission or prior authorization request for health care services and isNOT A GUARANTEE OF PAYMENT.

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