Board certification and accreditation required for TRUST providers performing sleep studies and polysomnography

As announced in the October Record, Blue Cross Blue Shield of Michigan’s new prior authorization requirement for sleep-testing services, effective Feb. 1, 2015, applies only to in-lab sleep testing. However, all sleep testing services for BCBSM commercial PPO members, whether an in-lab or home sleep test, must be performed and interpreted by a board-certified sleep medicine physician affiliated with an accredited sleep laboratory.

Providers in the TRUST network who do not meet BCBSM’s credentialing requirements as outlined below should not submit sleep study claims for PPO members. This violates the TRUST Provider Agreement, and such claims will be subject to audit and recovery. Providers who continue to submit such claims will be subject to termination of their TRUST contracts.

Physician board-certification requirement
TRUST physicians performing and/or interpreting polysomnography  services (*95810 -*95811-*95805- and *95808) and portable home sleep testing for Blue Cross PPO members are required to be board certified in sleep medicine. This requirement was effective April 1, 2010. TRUST physicians who do not have these credentials may perform the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.); however, they must refer their patients to board-certified sleep specialists in the TRUST network for all diagnostic sleep studies.

The sleep specialist is the physician responsible for determining and performing the most appropriate test(s) for the patient and obtaining preauthorization when required. It’s important that providers keep their certification information, including expiration dates, current with BCBSM in order to be able to submit preauthorization requests and perform such services.

Facility accreditation requirement
As another step in improving the quality and utilization of sleep services, beginning Feb. 1, 2016 all TRUST facilities performing polysomnography and home sleep testing for Blue Cross PPO members must be accredited by a BCBSM-designated accrediting body. 

For nonhospital-based sleep laboratories, Blue Cross requires accreditation by the American Academy of Sleep Medicine. Hospital-based sleep testing facilities must be accredited by AASM or an accreditation organization accepted under the Participating Hospital Agreement.

The offices of providers that only interpret polysomnography or other sleep testing results are not considered sleep laboratories and would not qualify for accreditation. To interpret polysomnography or home sleep test, however, the board-certified sleep specialist must be under the supervision of the director of a laboratory meeting BCBSM accreditation and board-certification requirements.

The 2016 effective date provides the opportunity for sleep-testing facilities that are not accredited to submit their application for accreditation. In the interim, providers not meeting this requirement may continue to provide services while working toward accreditation. Note: This accreditation requirement does not change the way BCBSM contracts with sleep-testing providers nor does it affect the billing location for services provided.

See October Record article
For additional information, please refer to the October 2014 Record article titled “Preauthorization required for in-lab sleep studies.”

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association.  All rights reserved.