As previously communicated, effective for dates of service on or after January 1, 2014, precertification is requiredfor Medicare Advantage HMO members for sleep studies and continuous positive airway pressure (CPAP) titration inthe facility setting (free-standing sleep study center or hospital sleep study lab). Note: This change was implemented forcommercial members on September 1, 2013.

AmeriHealth New Jersey has delegated the responsibility for precertification of sleep studies and CPAP titration studiesin the facility setting to AIM Specialty Health^SM (AIM). AIM uses their Sleep Disorder Management Diagnostic & TreatmentGuidelines, adopted by AmeriHealth New Jersey and available on their website at www.aimspecialtyhealth.com, to guidethe utilization of these services for our members. The guidelines involve integration of medical information from multiplesources to support the use of high-quality and state-of-the-art advanced sleep management services. The processfor criteria development is based on technology assessment and peer-reviewed medical literature, including clinicaloutcomes research and consensus opinion in medical practice. It takes into consideration recommendations from:

• American Academy of Sleep Medicine (AASM)
• American Thoracic Society (ATS)
• Agency for Healthcare Research and Quality (AHRQ)
• Centers for Medicare & Medicaid Services (CMS)

AmeriHealth New Jersey covers sleep studies conducted in the home setting, without precertification, when themedical necessity criteria outlined in Medical Policy #07.03.05o: Sleep Disorder Testing are met (#07.03.05p as ofJanuary 1, 2014). Precertification is not required for sleep studies that are conducted in the home setting. CPAPtitration in the home setting continues to require precertification through AmeriHealth New Jersey, based on thestandard rules for rental of durable medical equipment.

Members should obtain sleep studies and CPAP titration in the setting that is most appropriate for their condition, basedon factors such as:

• the setting that has been determined to be both cost-effective and safe for the member;
• the level of care required by the member based on his or her medical history and current health status;
• current standards in medical practice.

Member cost-sharing (deductible, coinsurance, and/or copayments) applies in accordance with the terms of themember?s benefit contract.

Obtaining precertification for the sleep studies in the facility setting

Providers who request coverage for administration of a sleep study in a facility setting are required to provide detailsabout the member?s medical history to support the request.

All precertification requests for sleep studies and CPAP titration in a facility setting should be submitted through theAIM ProviderPortal^SM, which can be accessed through the NaviNet^? web portal by selecting Authorizations from the Plan Transactions menu, then AIM.

It is very important that providers use NaviNet to verify member-specific requirements or refer to the most currentprecertification requirement list on our website. Failure to obtain precertification forany of the services that require it may result in a reduction in payment or nonpayment for the services not precertified.

If you have any questions about these changes to place-of-service options for sleep studies, please call CustomerService at 1-888-YOUR-AH1 (1-888-986-7241).

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