New Sleep Management Program to Begin December 1, 2017
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will implement a new specialty benefit management program for sleep testing and therapy services, effective December 1, 2017. The program is designed to improve convenience and compliance, and enhance health care affordability for our individual, under-65 members enrolled in insured and administered products.
The program will help physicians and clinicians:
- Improve site-specific appropriateness for sleep disorder testing and therapy services
- Better manage cost-effective equipment and services
- Monitor member compliance with prescribed sleep therapies
AIM Specialty Health® (AIM) will administer the program. AIM is a leading specialty benefits management company with a strong reputation for promoting clinical excellence, innovation, and provider service. AIM utilizes clinical criteria derived from leading evidence-based guidelines and literature regarding the use of clinical services, and is accredited by both URAC (Utilization Review Accreditation Commission) and the National Committee for Quality Assurance (NCQA).
The sleep management program will require prior authorization to be obtained from AIM for certain non-emergency, non-inpatient sleep tests and therapy services. This program will consider the medical necessity of the sleep study, as well as the clinical appropriateness of a facility test in comparison to a test done in the home. Prior authorization will also be required for any subsequent treatment (therapy), both initial and ongoing. Additionally, therapy services that require the continued rental of equipment and or replacement of supplies, will require usage criteria be met. These guidelines are available on the AIM website at: aimspecialtyhealth.com/gowebsleep.
AIM will review authorization requests for following outpatient tests and services:
- Home sleep test (HST)
- In-lab sleep study (PSG)
- Titration study
- Initial treatment order (APAP, CPAP, BPAP)
- Ongoing treatment order (APAP, CPAP, BPAP)
- Oral appliances
Effective December 1, 2017, eligible, under age-65 members enrolled in an insured or administered product, must have prior authorization from AIM before receiving an authorization-required sleep test or therapy service for a service date on or after December 1, 2017.
Beginning December 1, 2017, if you are a provider of sleep tests and or therapy services and have a patient considering an authorization-required sleep test and or therapy service, prior authorization from AIM must be obtained in advance of providing the test or service for that patient. Sleep tests and therapy services not preauthorized by AIM will be considered ineligible for payment under Blue Cross NC's program eligible, members' benefits. Note: If a predetermination about eligibility was made prior to December 1, 2017, that outcome will be recognized for the duration of that approval period.
The Sleep Management Prior Approval Code List is available on the Prior Plan Approval page of our website Blue Cross NC.com. Providers can begin contacting AIM, starting November 20th, 2017, to request authorizations for the sleep tests and or therapy services to be provided program eligible members, on and after December 1, 2017. Ordering physicians (those referring the member for sleep testing and therapy), DME suppliers, and servicing providers may submit requests for sleep testing and therapy on behalf of Blue Cross NC members.
Additional information about this new program for Blue Cross NC's program eligible, under age-65 members is available in the online Sleep Management FAQs for Providers, and at www.aimspecialtyhealth.com/gowebsleep. When accessing www.aimspecialtyhealth.com/gowebsleep, click on the link for "Sleep Management Frequently Asked Questions."
Blue Cross NC's new specialty benefit management program for sleep testing and therapy services will apply for eligible members who are enrolled in Blue Cross NC's under age-65 underwritten and administrative services only (ASO) products. Members enrolled through ASO employer groups may be program eligible and included, if program participation has been elected by the member's employer.
Membership enrolled through the North Carolina State Health Plan for Teachers and State Employees (SHP) is not eligible under the program at this time. However, sleep services performed in the home will continue to require prior authorizations to be obtained from Blue Cross NC, in advance of being provided SHP members.
Members of the Federal Employees Program and Blue Cross NC's Medicare Advantage (Blue MedicareSM) products are not program eligible. Additionally, BlueCard® members from other Plan areas will not be part of this program for Blue Cross NC members. However, BlueCard members may have similar programs through their Home Plans.