Harvard Pilgrim is updating our sleep studies and sleep therapies authorization program, and changes will include:
- Transitioning to a new vendor to oversee utilization management of sleep diagnostic studies
- Allowing coverage for 5 additional home sleep study codes with prior authorization
- Managing requests for sleep durable medical equipment (DME) directly at Harvard Pilgrim
New vendor for sleep studies authorization
Effective for dates of service beginning Sept. 1, 2017, National Imaging Associates, Inc. (NIA) will provide utilization management for sleep diagnostic services, including attended and home sleep studies, for members age 18 or older with a risk of sleep disorder who are enrolled in Harvard Pilgrim HMO, POS, PPO, and Access America products. Prior authorization is not required for sleep diagnostic services for members under age 18.
In addition to G0399, which currently is eligible for coverage, the following five home sleep study CPT and HCPCS codes will also be eligible for coverage with prior authorization under the updated program:
- 95800 – Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time.
- 95801 – Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone).
- 95806 – Sleep study, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement).
- G0398 – Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort, and oxygen saturation.
- G0400 – Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.
These codes will be added to the applicable Harvard Pilgrim fee schedules.
The following attended sleep study codes will continue to require prior authorization: 95805, 95807, 95808, 95810, and 95811.
Authorization requests for sleep studies
NIA currently oversees utilization management for radiology and select spine services for Harvard Pilgrim, and providers should request prior authorization for sleep studies in the same way:
Providers may begin making prior authorization requests for sleep studies through NIA on Aug. 28, 2017 for dates of service of Sept. 1, 2017 and beyond. Our current sleep vendor, eviCore, will continue to accept requests for prior authorization for sleep diagnostic and sleep therapy services through Aug. 31, 2017. Any authorizations granted by eviCore will be honored and transferred to Harvard Pilgrim to ensure accurate claims adjudication.
When requesting prior authorization, providers should be prepared to provide the information noted in the Sleep Assessment Records Checklist.
Requests for sleep therapy equipment
Harvard Pilgrim will directly manage requests from DME providers for non-invasive airway assist devices (CPAP, APAP and BiPAP) and related sleep study supplies, beginning Sept. 1, 2017.
For commercial members age 18 or older, authorization is required for the following sleep therapy equipment: A4604; A7027-A7037; A7044-A7046; E0470-E0471; E0561-E0562; E0601. Notification/authorization is not required for these two sleep-related devices: A7038 and A7039.
DME providers should submit requests to Harvard Pilgrim’s Referral and Authorization Unit at least one week prior to the date of service in one of the following ways:
- Electronically via HPHConnect or NEHEN
- By phone: 800-708-4414
- By fax: 800-232-0816
DME providers will receive approval to provide the member with CPAP for 4 months (the 3-month rental period and fourth month in which the unit is purchased). Approvals for BiPAP equipment provide for 12 months of use; the DME provider should contact Harvard Pilgrim prior to the end of the 12th month to secure approval for the final 3 months of use/purchase.
Harvard Pilgrim will continue to be responsible for claims adjudication. Failure to obtain authorization in advance of conducting a sleep study or supplying sleep therapy equipment will result in an administrative denial of the claim, and the provider will be held liable for the charges.
Updated policies and criteria
For complete information, please refer to the following updated policies:
Look to future issues of Network Matters for additional information. For any further questions, please contact Harvard Pilgrim’s Provider Service Center at 800-708-4414.