The Record - Preauthorization required for in-lab sleep studies

Reminder: Sleep study referral requirements

TRUST physicians must refer patients with a suspected sleep disorder to other TRUST board certified sleep medicine physicians for all sleep study services. Certified sleep specialists can be identified by using the Find a Doctor feature on bcbsm.com.

All TRUST M.D.s and D.O.s performing sleep study services for our PPO members must be certified in sleep medicine by a board recognized by Blue Cross. We recognize the American Board of Sleep Medicine and the sleep medicine boards approved by the American Board of Medical Specialties and the American Osteopathic Association. The sleep specialist is the physician responsible for obtaining preauthorization for sleep testing when required and performing the testing in an accredited sleep laboratory.

Non-board certified physicians submitting sleep study claims for PPO members will be subject to audit and recovery based on the physicians failure to meet a necessary privileging credential. Such claim submissions are considered a violation of the TRUST Provider Agreement and any non-credentialed physicians submitting sleep study claims may be subject to termination of their TRUST contract.

Effective for dates of service on or after Feb. 1, 2015, Blue Cross Blue Shield of Michigan will require preauthorization for in-lab sleep testing by instate providers for non-Medicare Blue Cross PPO members. Specifically, preapproval must be obtained for the following Current Procedural Terminology codes: *95805, *95807, *95808, *95810 and *95811. All authorized attended sleep study services should be performed at a laboratory or center accredited by the American Academy of Sleep Medicine or The Joint Commission.

CPT codes *95782 and *95783 are excluded from preauthorization. In addition, providers are not required to obtain preauthorization for *95806. Home sleep testing followed by auto positive airway pressure is a viable alternative to in-lab sleep diagnostic studies and CPAP titration for many patients with a high pretest probability of obstructive sleep apnea. HST can be a more affordable, comfortable and convenient option for such patients. In spite of this, we find HST significantly underutilized in our patient population. Preauthorization of in-lab sleep testing and the shifting of select patients to the home setting will provide more efficient utilization of resources for the management of obstructive sleep apnea and other sleep disorders.

Preauthorization process
Only board certified sleep medicine physicians are allowed to submit a preauthorization request. Preauthorization requests are managed by AIM Specialty Health. Requests should be submitted online 24/7 through AIM’s ProviderPortal^SM at AIMSpecialtyhealth.com**. Alternatively, providers may submit a request via phone at 1-800-728-8008, 8 a.m. to 5 p.m. Eastern time Monday through Friday.

AIM will perform a clinical evaluation of the request and provide a determination to the provider. The clinical criteria used by AIM are available on AIM’s website.

Providers are expected to obtain an authorization before administering the service. Retrospective authorization requests are permitted, but only up to 60 days past the date of service. Such requests must be done by phone, and there is no guarantee that an already administered test will be authorized.

Providers are able to request a preauthorization up to 30 days before the scheduled date of service. Sleep specialists may begin submitting preauthorization requests to AIM as of Jan. 1, 2015.

Please note that authorizations are only valid for a time period of up to 30 days before to 30 days after the anticipated date of service identified to AIM in the authorization request. Should an authorized sleep study get rescheduled, the provider must contact AIM again if the new date of service is going to be outside the valid time range for the initial anticipated date of service.

It is very important that providers, including hospitals billing for the sleep study technical component, confirm an authorization has been issued before the service is rendered. Preauthorization requests can be checked by logging into AIM’s provider online portal or by phone.

AIM registration and training opportunities
To register with AIM’s ProviderPortal, visit AIMSpecialtyhealth.com** and click on Register Now under the ProviderPortal login page. Providers will need to supply the following information:

AIM will be hosting online training webinars for providers on the registration and preauthorization request process. The training webinar schedule is listed below.

Note: The preauthorization requirements described in this article do not apply to State of Michigan members, Federal Employees Program^® members, Ascension or Medicare Advantage PPO members or non-Michigan residents. In addition, authorization is not required for non-attended sleep testing codes or studies performed in inpatient, observation or emergency room settings.