Our Sleep Medicine program is an extension to our existing utilization management (UM) program. The program is designed to manage testing and therapy services for sleep disorders and is administered by Carelon Medical Benefits Management (Carelon). Services managed under this program include:
- Titration studies
- Oral appliances for sleep therapy
- In-lab sleep studies (polysomnography [PSG])
- Initial treatment order (automatic positive airway pressure [APAP], continuous positive airway pressure [CPAP], bilevel positive airway pressure [BiPAP])
Ongoing treatment orders (APAP, CPAP or BiPAP)
Physicians and other health care professionals ordering services listed above must first contact Carelon to request pre-authorization prior to services being rendered. View the codes that require pre-authorization on our Pre-authorization Lists.
Use the tabs below to learn more about our Sleep Medicine program.
This program applies to procedures performed in the following settings:
- Free-standing sleep center
- Outpatient hospital setting
Outpatient basis in a physician office
Providers should contact Carelon to request pre-authorization before scheduling or performing any facility-based diagnostic or titration study (free-standing or hospital), as well as for sleep treatment equipment and related supplies. Authorization for ongoing sleep therapy will be dependent on member compliance data provided to Carelon by the durable medical equipment (DME) vendor.
Notes:
- Supplies for APAP, CPAP and BiPAP do not require pre-authorization
- Home sleep testing (HST) does not require pre-authorization
- Compliance information for APAP, CPAP, BiPAP must only be submitted during the rent-to-purchase period. Once the equipment has been purchased, we do not require compliance information.
- Services performed in conjunction with any of the following are excluded from the program:
- Urgent care facilities
- Inpatient hospitalization
- Emergency room services
- The program applies to new and existing sleep therapy patients.
- Ordering physicians (those referring the member for sleep testing) and servicing providers (free-standing or hospital laboratories that perform sleep testing) may submit order requests.
- If Carelon determines the service does not meet medical necessity criteria, the requested procedure will be denied.
- If a sleep medicine provider performs the service without authorization, the procedure will be considered a provider write-off and cannot be billed to the member.
This program applies to all members residing in Idaho, Oregon, Utah and Washington.
Providers serving members outside our four-state service area are not required to participate in this program, but they are encouraged to do so. Out-of-state providers can choose to contact Carelon to receive an order number prior to scheduling the service. As this authorization is not a requirement, the claim will be reviewed for medical necessity once received.
Those excluded from this program include:
- Medigap members in Utah
- Any member where we are in the secondary health plan coverage position
- Out-of-network providers for exclusive provider organization (EPO) members (Note: Members on EPO products in Utah do not have out-of-network benefits. Services rendered by out-of-network providers are non-covered services.)
Ordering physicians (those who refer the member for sleep testing and therapy) and servicing providers (those who provide the sleep testing and therapy) may submit requests for sleep testing and therapy on behalf of members. Note: DME suppliers may only submit requests for sleep therapy services.
Contact Carelon online via Carelon's ProviderPortal or call toll-free at 1 (877) 291-0509, 8 a.m. - 5 p.m. PST Monday through Friday to request pre-authorization. Requests submitted online may receive automated approval.
- Login or register with Carelon's ProviderPortal
- Phone 1 (877) 291-0509
View workarounds for Carelon system outages
View the codes that require pre-authorization on our Pre-authorization List.
Providers currently using Carelon's website for radiology authorizations do not need to register again. All other providers who will require access to the Carelon website to obtain authorization or check on authorization status must register. For large group practices, Carelon can help with the registration process.
- Phone 1 (877) 291-0509
Facilities, sleep laboratories, and DME providers must complete an online assessment on OptiNet.
OptiNet is an online provider registration tool that collects information on the facility, such as services, staffing and accreditation. Facility, sleep laboratory and DME provider data provided will become an important part of the information available to ordering physicians and members.
To be included in Carelon's OptiNet directory, you must complete an online assessment. If you have not previously registered with Carelon, you will first need to do so. The registration tool is available through the ProviderPortal.
You can complete your OptiNet registration at your convenience; you can initiate, pause and save your progress as needed. Select BridgeSpan from the drop-down menu, and proceed with the assessment.
Note: You do not need to complete the survey if you only read sleep testing results and do not perform the technical and/or global component of these services.
The information gathered from the OptiNet registration will:
- Be made available to ordering physicians during the sleep management request process and used to educate users in the Provider Selection component of the order request process.
- Allow ordering physicians to choose a servicing provider from the online directory based on their ability to provide home sleep testing, facility-based sleep testing and DME services.