Attention: DME Providers CPAP, BIPAP Authorization Requirement Update, Effective March 01, 2017
Posted on February 27, 2017
As you are aware, Health New England partners with eviCore healthcare to pre-authorize specific sleep diagnostic procedures and Positive Airway Pressure (PAP) therapy devices and supplies. Our partnership with eviCore healthcare has helped Health New England improve the quality and appropriateness of these services.
We are now more than a year into our partnership and we have most recently discussed additional ways to enhance the quality of the program.
An important component of the use of PAP Therapy devices is member compliance. For the first 90 days of PAP Therapy, Durable Medical Equipment (DME) providers must install PAP devices with remote monitoring capability via modem. Beyond 90 days of therapy, periodic monitoring through SD card (or similar) reporting of daily adherence/compliance is required.
Effective, March 01, 2017, eviCore will no longer issue authorization for a six month time period for CPAP (Continuous Positive Airway Pressure) or BIPAP (Bi-level Positive Airway Pressure) devices for the Initial Request. The initial authorization is required for the device and will be valid for the first 90 days only. Upon meeting compliance, eviCore will send notification to the referring provider, DME provider, and the member with approval or denial. If an approval is granted the DME provider will receive an additional 7-10 month extension of the authorization (depending on line of business and your contracted terms). If a denial is received, the DME provider is not authorized to bill any subsequent months for the device to the health plan. Ongoing maintenance supplies will be authorized with a six-month time period.
In addition, if you are making a change to transfer a member from a CPAP to a BIPAP device, you must contact eviCore to request an authorization change. These requests must be made via phone call by contacting eviCore at (800) 918-8924 This specific authorization change cannot be processed through the eviCore web portal. Also, if you are made aware a member you are rendering Sleep Service care for has changed providers, it is important that either the servicing provider or member contact eviCore to close any outstanding authorizations that may be in place. It is up to the new servicing provider to request authorization.
If you have any questions regarding any of the included information, please contact Provider Relations at 1-800-842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 4:30 p.m.
Sincerely,
Liane Comeau
Provider Relations Manager
