Here are highlights of our policy regarding sleep studies

Some providers have told us they have questions about Blue Cross Blue Shield of Michigan’s policy regarding sleep studies. We haven’t communicated about our policy in The Record for a few years, so we’d like to provide an overview of our policy for our Blue Cross commercial members and our Medicare Plus Blue℠ members.

Physician board-certification requirement

• To perform and get reimbursed for in-center or out-of-center sleep testing, a doctor must be board-certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine.

• Any physician may order the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.), but they must refer their patients to board-certified sleep specialists in the network for all diagnostic sleep studies.

• Any M.D. or D.O. may prescribe a sleep test, however, the performing physician must be board-certified in sleep medicine.

Facility accreditation requirement

• All in-lab sleep testing services for Blue Cross commercial members and Medicare Plus Blue members must be performed by an accredited sleep laboratory.
• Facilities performing polysomnography must be accredited by a Blue Cross Blue Shield of Michigan-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.

Prior authorization process

For Blue Cross commercial and Medicare Plus Blue members, prior authorization requests for sleep studies must be submitted to AIM Specialty Health®. Here’s more information about that:

• All physician specialties can submit a prior authorization request. Requests can be submitted online 24/7 through AIM’s ProviderPortal℠ 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. However, retroactive authorization requests are permitted, but only up to 90 days past the date of service. Such requests must be requested by phone or through the portal, and there is no guarantee that an already administered test will be authorized. This is a provider liability authorization program.
• Providers can request a prior authorization up to 30 days before the scheduled date of service.
• Prior authorization must be obtained for the following CPT codes: *95805, *95807, *95808, *95810 and *95811.
• Currently, the AIM Specialty Health Sleep program doesn’t require prior authorization for the following services:
• CPT codes *95782 and *95783 (polysomnography, younger than 6 years)
• CPT code *95806 (home testing)
• Home sleep testing services don’t require prior authorization from AIM Specialty Health^®.

Notes:

• Authorizations are only valid for a time frame of up to 30 days after the anticipated date of service identified in the authorization request. Should an authorized sleep study get rescheduled outside the valid time frame from the initial anticipated date of service, the provider must request a new authorization.
• These prior authorization rules regarding AIM don’t apply to sleep studies for Blue Care Network commercial or BCN Advantage℠ members. For information on prior authorization requirements for those members, see the BCN Sleep Management Program webpage on the ereferrals.bcbsm.com website.)

For more information, see the “Polysomnography and other sleep testing” section of the Blue Cross PPO Provider Manual and the “Preauthorization of advanced imaging, cardiology and in-lab sleep study services — AIM Specialty Health” section of the Medicare Plus Blue PPO provider manual You can also reference the medical policy using the Medical Policy & Pre-Cert/Pre-Auth Router.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.