Prior authorization requirements for sleep testing and treatment
For these services, we require prior authorization for all commercial and Medicare Advantage members. Authorization is not required for Federal Employees Program (FEP) members.1
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How to submit a prior authorization request
Carelon Medical Benefits Management is the company that administers the prior authorization program for us. Carelon uses our medical policies to identify the clinical appropriateness of home or lab testing:
- Sleep Disorder Management (969)
- Sleep Disorder Management CPT and HCPCS Codes (970)
- Medicare Advantage High Tech Radiology and Sleep Disorder Management (923)
On our medical policy site, search for "sleep."
Ordering clinicians
Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact Carelon to request prior authorization:
- Through a direct link on this site (no additional registration is required). In the eTools tab, go to Carelon. Click the Go Now button.
- Go directly to the Carelon ProviderPortal (registration is required)
- Go to www.providerportal.com
- Call Carelon’s Contact Center at 1-866-745-1783
- Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, Carelon will respond the next business day.
Free-standing labs, hospitals, and DME vendors
Check with Carelon to make sure an authorization is in place before rendering services. Authorization for ongoing sleep therapy supplies will be dependent on member utilization of the equipment. The DME vendor will be required to provide utilization data to Carelon when requesting authorization for ongoing treatment.
1. For FEP, prior approval is required for sleep studies performed in a location other than the home. Fax prior authorization requests to us at 1-888-282-1315.
