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Precertification and compliance monitoring for PAP machines and supplies

January 30, 2015

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In an effort to help our members receive appropriate, safe, and affordable care for obstructive sleep apnea (OSA) and other sleep disorders, Independence has partnered with AIM Specialty Health® (AIM), an independent company. The goal is to streamline the precertification process for sleep studies, APAP, BPAP, and CPAP (PAP) machines and supplies (e.g., tubing, water chambers, masks) and enhance member compliance with prescribed usage.

Precertification requirements

As of January 1, 2015, in addition to obtaining precertification for PAP machines, durable medical equipment (DME) providers are also required to obtain precertification for all related supplies. This requirement applies to all new and existing patients on PAP therapy.

Currently, ordering providers request precertification of sleep studies and CPAP titration studies in the facility setting through AIM. Beginning on February 16, 2015, DME providers will be required to submit precertification requests for PAP machines and all related supplies (e.g., tubing, water chambers, masks) through AIM.

We are making enhancements to the NaviNet® web portal to accommodate the submission of precertification requests through the AIM Provider PortalSM using the AIM transaction. Once implemented, providers must obtain precertification through AIM.

Note: Until the enhancements are completed, providers should continue to submit precertification requests for PAP machines and supplies using the Authorizations transaction in NaviNet. We will post a notification on NaviNet Plan Central once the AIM Provider PortalSM is updated.

Compliance monitoring requirements

To ensure that our members are using their PAP machines as prescribed by the ordering provider, AIM incorporates a compliance element to their precertification process, which will begin on February 16, 2015. Usage data will be collected for all members using PAP therapy. This data will be analyzed by AIM to determine if the member has been compliant in using their PAP machine and if a request for precertification of continued rental and/or supplies will be approved or denied.

For members who are new to PAP therapy, DME providers must contact AIM to request approval for the initial PAP set-up, prior to dispensing equipment and supplies. For those members currently on PAP therapy, the DME provider must also contact AIM to request approval for on-going treatment. DME providers will need to submit the date upon which the member initiated PAP therapy on the current device ? regardless of payer. The AIM system will then calculate where the member is in the rental cycle, if applicable.

Please note the following when requesting precertification through AIM:

  • Rentals. During the rental period, the precertification will cover the PAP machine, humidifier, and all supplies. The precertification will be good for 90 days.
  • Owned. Once the rental period ends, the precertification will only cover supplies (A-codes). The precertification will be good for one year.
If AIM denies a precertification request after analyzing the compliance data, a denial letter will be mailed to the DME provider, the ordering provider, and the member. This notification encourages the ordering provider to contact the member and determine the appropriate next steps.

Guidelines

Independence will adopt and follow AIM's Clinical Guidelines, which are available on AIM's website, when reviewing precertification requests for our commercial members. AIM will follow the established Medicare coverage guidance when reviewing requests for our Medicare Advantage HMO and PPO members. Policy Notifications for the following policies, which address sleep disorder testing, are available on our Medical Policy portal. Included within the policies are links to the guidelines that AIM will use to determine usage compliance and medical necessity for PAP machines and supplies, a complete list of codes that require precertification, and quantity limits set for the supplies.

  • Commercial: #07.03.05r: Sleep Disorder Testing and Positive Airway Pressure Therapy
  • Medicare Advantage: #MA07.058a: Sleep Disorder Testing and Positive Airway Pressure Therapy
Please call 1-800-ASK-BLUE (1-800-275-2583) if you have any questions.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.

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