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

In the January 2015 Record, we let you know that TRUST providers need to comply with accreditation requirements for performing sleep studies and polysomnography. We subsequently informed you via web-DENIS that Traditional providers must also comply. We’ve revised the original article to include this additional information and are providing it here for your reference.

Blue Cross Blue Shield of Michigan’s prior authorization requirement for sleep-testing services, effective Feb. 1, 2015, applies only to in-lab sleep testing. However, all sleep testing services for Blue Cross 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 or Traditional networks who don’t meet Blue Cross’ credentialing requirements as outlined below shouldn’t submit sleep study claims for members. This violates our provider agreements, and such claims will be subject to audit and recovery. Providers who continue to submit such claims will be subject to termination of their contracts.

Physician board-certification requirement
Physicians performing or interpreting polysomnography services and portable home sleep testing for Blue Cross members are required to be board-certified in sleep medicine. This requirement was effective April 1, 2010. Physicians who don’t 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 our networks 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 Blue Cross 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 facilities performing polysomnography and home sleep testing for Blue Cross members must be accredited by a Blue Cross-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 aren’t considered sleep laboratories and wouldn’t 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 Blue Cross accreditation and board-certification requirements.

Note: This accreditation requirement doesn’t change the way Blue Cross contracts with sleep-testing providers nor does it affect the billing location for services provided.