November 2018

Changes to Home-based Sleep Study Benefit Prior Approval Requirements for Some FEP Members

In January 2017, benefit prior approval requirements for sleep studies performed outside the home were implemented for some Federal Employee Program^® (FEP) members. Claims and appeals revealed that when outpatient facilities submitted claims for the equipment used for home-based sleep studies, our claims system presumed the services took place outside the home. For home-based sleep studies, this issue resulted in higher copayments and claim denials for FEP Basic Option members.

FEP made changes to correct this issue. Effective Sept. 4, 2018, the following unattended sleep study and portable test monitor procedure codes, when billed by outpatient facilities, are considered eligible home-based sleep studies that no longer require benefit prior approval:

• 95800
• 95801
• 95806
• G0398
• G0399
• G0400

Benefit prior approval continues to be required for all sleep studies performed outside the home.

As a reminder, it is important to check eligibility and benefits for all members. This step will help you verify membership and other important details, such as copayment, coinsurance, deductible amounts and whether benefit prior approval may be required for a member/service. We encourage you to check eligibility and benefits online using the Availity^® Provider Portal, or your preferred web vendor. If you do not have web access, or need to obtain benefits specific to sleep studies, you may call 800-972-8382 to check eligibility and benefits for FEP members.

This material if for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized or obtained benefit prior approval is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.