DME Billing Alert: BCBS of NC Implementing Major Changes to Sleep Therapy Policies

BCBSNC-300x150Blue Cross and Blue Shield of North Carolina (BCBSNC) will implement a new Sleep Management Program effective June 1, 2017. The new program will consider the medical necessity of studies and the clinical appropriateness of a facility- or home-based test. Prior authorization will also be required for coverage of any subsequent treatment (therapy), both initial and ongoing.

For therapy services, members must meet usage criteria for the continued coverage of rental equipment and replacement of supplies. Servicing providers’ claims and durable medical equipment (DME) providers’ claims for equipment and supplies adjudicate based on the benefit approval or denial outcome.

Providers must submit a prior authorization request and specified clinical information for home and facility-based sleep testing services scheduled to begin on or after June 1, 2017, which will result in the approval or denial of coverage for these following non-emergency, outpatient and/or facility and home-based sleep testing and therapy services:

  • Home sleep test (HST)
  • In-lab sleep study (PSG)
  • Titration study
  • Initial treatment order (APAP, CPAP, BPAP, and oral devices, appliances and related supplies)
  • Ongoing treatment order (APAP, CPAP, BPAP, and oral devices, appliances and related supplies)

Both ordering physicians (those referring the member for sleep testing and therapy) and servicing providers may submit requests for sleep testing and therapy on behalf of BCBSNC members. DME suppliers may submit requests for sleep therapy services.

The program will be administered by AIM Specialty Health®. If a predetermination eligibility was determined prior to June 1, 2017, that outcome will be recognized for the duration of that approval period.

As of June 1, 2017, the Sleep Management Prior Approval Code List will require prior authorization through the AIM portal or by phone.

This list is updated on a quarterly basis, within the first 10 days of January, April, July and October. If there is no update within this time period, the list will remain unchanged until the following quarter. Unlisted and miscellaneous health services codes should only be used if a specific code has not been established by the American Medical Association.

To request prior approval for sleep management, visit the AIM ProviderPortal℠ in Blue e or call AIM Specialty Health at (866) 455-8414 Monday – Friday, 8 a.m. – 6 p.m., EST.

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