Effective for dates of service beginning Nov. 20, 2020, Harvard Pilgrim will be adopting InterQual criteria for commercial medical review of positive airway pressure (PAP) devices for obstructive sleep apnea (OSA).
Harvard Pilgrim currently requires prior authorization for the following HCPCS codes for members 18 years of age or older and will continue to do so, but prior authorization will be managed by InterQual:
- E0601 – Continuous positive airway pressure (CPAP) device
- E0470 – Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
- E0471 – Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
Please note that the authorization request details for these devices are changing as a result of InterQual criteria adoption. To obtain a CPAP device (E0601), you will need to submit one authorization request for the initial three-month rental period and then another request for the final purchase of the device after the initial three-month rental period is complete. For a respiratory assist device (E0470 or E0471), the initial authorization is good for a 12-month rental period. These devices may be reimbursed for a count of up to 15 months, but you will need to submit a second authorization request for the additional three months once the initial rental period has ended.
With the adoption of InterQual criteria, when submitting your authorization request through HPHConnect, electronic authorization questionnaires will guide you through the criteria. For guidance on using HPHConnect to request an authorization and accessing the InterQual criteria, refer to this training presentation. To request additional training, contact us at Provider_Experience@harvardpilgrim.org. While Harvard Pilgrim encourages providers to request authorization electronically, we will continue to accept authorization requests by phone (800-708-4414) or fax (800-232-0816).
For more information, please refer to Harvard Pilgrim’s new Positive Airway Pressure Devices for Sleep Apnea Medical Policy. You may view and print the applicable SmartSheet questionnaires via HPHConnect (go to www.harvardpilgrim.org/providerportal, select Resources and then the Upcoming InterQual link).
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