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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

August 2017

New Sleep Program Reminder and FAQ


As a reminder, effective Sept. 1, 2017, Harvard Pilgrim is updating our sleep studies and sleep therapies authorization program. Changes will include:

  • Transitioning to a new vendor, National Imaging Associates, Inc. (NIA), to oversee utilization management of sleep diagnostic studies, including attended and home sleep studies, for members age 18 or older with a risk of sleep disorders who are enrolled in Harvard Pilgrim HMO, POS, PPO, and Access America products.
  • Allowing coverage for the following 5 additional home sleep study codes with prior authorization: 95800; 95801; 95806; G0398; and G0400 — which are being added to applicable Harvard Pilgrim fee schedules. (G0399 is currently eligible for coverage and will remain covered.)
  • Managing requests for sleep durable medical equipment (DME) directly at Harvard Pilgrim.

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.

How to Request Prior Authorization – For Dates of Service Beginning Sept. 1, 2017

For sleep studies

For sleep DME

Contact NIA beginning Aug. 28, 2017 either:

Note: New users can register for access at www.radmd.com by clicking on “New User” and following the instructions; access is granted within 1-2 days. Existing RadMD users may use their current account.

Contact 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

For further details — including information about the transition; guidance on how to request authorization for sleep studies and sleep therapy equipment; and links to updated policies — please refer to the June issue of Network Matters and our Frequently Asked Questions.

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Services

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator